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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004112
Report Date: 02/08/2022
Date Signed: 02/08/2022 01:13:27 PM

Document Has Been Signed on 02/08/2022 01:13 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VERONA COURT XFACILITY NUMBER:
306004112
ADMINISTRATOR:JULIE GORORDOFACILITY TYPE:
740
ADDRESS:25691 SABINA AVENUETELEPHONE:
(949) 916-2699
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Arda KardjianTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted and granted entry into the facility. LPA met with Arda Kardjian, Administrator and explained the nature of the visit.

LPA began the tour of the facility accompanied by Administrator. The facility currently has 5 residents in care. LPA observed one resident in living room watching television upon entry and remainder of residents in their bedrooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff and resident. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed a supply of emergency food and water as well as first aid kits in the facility. Facility has a supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed a shaded outside space for resident, area is used for outdoor visitation area as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are currently single occupancy. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA signed the hard copy available at facility for their records.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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