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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005669
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:18:00 PM

Document Has Been Signed on 12/11/2024 03:18 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 XIFACILITY NUMBER:
306005669
ADMINISTRATOR/
DIRECTOR:
ARDA KARDJIAN RN, BSNFACILITY TYPE:
740
ADDRESS:29571 IVY GLENN DRTELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Julie Gorordo, Arda KardjianTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Assistant Administrator Julie Gorordo and Administrator Arda Kardjian and explained the reason for the visit. Arda Kardjian Administrator's certificate expires on September 19, 2025. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for 6. LPA and Administrators toured the facility. The facility is a single story home with 8 bedrooms, 2 for staff and 6 for residents, 6 bathrooms, kitchen, living room, dining room and a two car garage. LPA observed the See Something, Say Something poster (PUB 475) posted next to the entrance. LPA observed the requires facility postings posted in the hallway. LPA observed all the resident rooms had the required furnishings. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all bathrooms are clean and operational. Hot water in all bathrooms measured between 108.5 and 109,9 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the 5 burner gas stove lights unassisted. The fire extinguisher in the kitchen is fully charged. LPA observed the knives are kept locked in a kitchen drawer. LPA observed the cleaning supplies are kept locked under the kitchen sink. The garage is kept locked and used for storage. No obstacles or hazards observed in the facility. LPA and Administrators toured the backyard. No bodies of water observed. There is a table with chairs and an umbrella to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA inspected the garage. . LPA observed the medication is kept locked in cabinet in the hallway. LPA inspected the first aid kit. The first aid kit has all the required elements. The last emergency drill took place on December 9, 2024. LPA reviewed 2 staff files, both staff are background cleared and associated to the facility. No discrepancies observed in the staff files. LPA reviewed 6 resident files and medications, no discrepancies observed. Facility has a dedicated internet device for resident use. 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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