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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002427
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:58:19 PM

Document Has Been Signed on 08/30/2024 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VERONA COURT IIIFACILITY NUMBER:
306002427
ADMINISTRATOR/
DIRECTOR:		ARDA KARDJIAN/TAREK ELNABLFACILITY TYPE:
740
ADDRESS:25701 SABINA AVENUETELEPHONE:
(949) 215-3017
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Julie Gorordo- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:02 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA met with Administrator Julie Gorordo and explained the reason for the visit.

Facility is licensed to serve six (6) non-ambulatory residents and maintains a hospice waiver for six (6). There are six residents in care during today's visit with two caregivers on duty and one reliever staff off duty.

LPA conducted a tour of the physical plant. The single story home consists of six resident bedrooms and two resident bathrooms. There are two staff bedrooms and one staff bathroom. LPA inspected all common areas including the attached two car garage. LPA observed the facility to be clean, sanitary, and in good repair. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 114.0 and 113.5 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two day supply of perishables and seven day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. LPA observed sufficient seating and shading. There was no body of water. A shed in the yard utilized as a storage was secured and inaccessible to residents. Facility maintains a fire extinguisher which was mounted, charged, and serviced on December 15, 2023. The auditory devices and dual-functioning smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency disaster supplies including food/water in the two closets. Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERONA COURT III
FACILITY NUMBER: 306002427
VISIT DATE: 08/30/2024
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LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size. The Administrator's Certificate for Arda Kardijian expires on September 19, 2025 and July 17, 2025 for Julie Gorordo.

LPA conducted an audit of six residents' files and three personnel files. No discrepancies were noted. Medications were audited for six residents. No discrepancies noted. Staff and resident interviews were conducted.

Based on the observations made during today's visit, no deficiency is being cited today.

An exit interview was conducted with Administrator Julie Gorordo, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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