<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004113
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:19:01 PM

Document Has Been Signed on 10/29/2021 12:19 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 IXFACILITY NUMBER:
306004113
ADMINISTRATOR:ARDA KARDJIANFACILITY TYPE:
740
ADDRESS:29842 ANDREA WAYTELEPHONE:
(949) 545-6698
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Julie SandersTIME COMPLETED:
12:32 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA's) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs were screened for symptoms of Covid. There is no PUB 475 poster posted in the entrance way. LPAs observed all staff were wearing mask. Administrator (AD)Julie arrived at 9:50am. LPAs and AD toured the facility. LPAs observed all resident bedrooms had the required furniture and had enough space to accommodate the resident and their belongings. LPAs inspected the bathrooms. All bathrooms were clean and operational. Hot water measured 116.9 degrees Fahrenheit to 119.8 degrees Fahrenheit. LPAs inspected the kitchen. LPAs observed the facility has a 2-day perishable and a 7-day non-perishable food supply on hand. LPAs observed medication is locked in the kitchen pantry. LPAs observed knives are kept locked in a kitchen drawer. LPAs inspected the facility garage. The garage is used for storage and kept secure from residents. LPAs inspected the First Aid kit. The First Aid kit had all the required elements. LPAs toured the backyard of the facility. No bodies of water observed. There's a sitting area with a table, chairs, and umbrella for sitting outside. The exit gate on the East side of the facility is operational. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1