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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005669
Report Date:
11/17/2022
Date Signed:
11/17/2022 04:16:38 PM
Document Has Been Signed on
11/17/2022 04:16 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 XI
FACILITY NUMBER:
306005669
ADMINISTRATOR:
ARDA KARDJIAN RN, BSN
FACILITY TYPE:
740
ADDRESS:
29571 IVY GLENN DR
TELEPHONE:
(949) 230-3797
CITY:
LAGUNA NIGUEL
STATE:
CA
ZIP CODE:
92677
CAPACITY:
6
CENSUS:
6
DATE:
11/17/2022
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Arda Kardjian
TIME COMPLETED:
04:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the post licensing visit. LPA met with Administrator Arda Kardjian and Assistant Administrator Julie Gorordo. LPA explained the reason for the visit. LPA and Assistant Administrator toured the facility. LPA observed all bedrooms had the required furnishings and were clean and organized. All bathrooms were clean and operational. Hot water measured 112.8 degrees Fahrenheit. LPA toured the kitchen. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the knives and sharp objects are kept locked in a kitchen drawer. LPA observed medication is kept locked in the hallway cabinets. LPA and Administrator toured the backyard. LPA observed a table with chairs and an umbrella for residents to sit outside. No bodies of water observed. Both exit gates are operational. No obstacles or hazards observed inside or outside of the facility. LPA toured the garage. The garage is used for storage and kept secured. LPA observed extra food and supplies in the garage. LPA consulted with the Administrator concerning reporting requirements and continued Covid-19 mitigation. No deficiencies observed during the visit. 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:
11/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/17/2022
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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