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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006243
Report Date: 12/16/2022
Date Signed: 12/16/2022 11:11:12 AM

Document Has Been Signed on 12/16/2022 11:11 AM - 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 XIVFACILITY NUMBER:
306006243
ADMINISTRATOR:KARDJIAN, ARDAFACILITY TYPE:
740
ADDRESS:23952 HILLHURST DR.TELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
12/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Arda KardjianTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with applicant Arda Kardjian. An application to operate a Residential Care Facility for the Elderly (RCFE) dated 7/28/2022 was received by Community Care Licensing (CCL). Facility has a capacity for 6 non-ambulatory and 0 (zero) bedridden. Facility has requested a Hospice waiver for 6. Facility phone number is 949-249-3483. LPA along with the applicant toured the facility and observed the following: Structure: Facility is a single story home with 7 bedrooms (1 bedroom is for staff), 5 bathrooms (1 bathroom is in the staff bedroom), living room, dining room and a two car attached garage. LPA observed the See Something, Say Something Poster (PUB 475) and the Ombudsman poster posted in the entry way of the facility. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. LPA observed the living room fireplace is screened. Living room has a TV for residents. Resident Bedrooms: All resident rooms are private single occupancy rooms. All rooms are equipped with a bed, chair, night stand, lamp and a closet. Bathrooms: All resident bathrooms are clean and operational and have a non-skid surface in the shower. Facility has hand soap and paper towels in the restrooms as well as hand washing signs posted. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for residents in care. Emergency Phone Numbers, Postings and Exit Plan: Emergency exit plan posted. LPA did not observe the postings for; Emergency phone numbers for the Fire Department or Law enforcement, the admission agreement notice and the Facility Theft and Loss policy. Food Service: LPA observed the kitchen is clean and organized. Facility has 2 day perishables and 7 day non-perishable food supply on hand in the kitchen. LPA observed emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and are operational. Fire extinguishers were all serviced on 10/31/2022. Appliances: Refrigerator, microwave, washer, and dryer are clean and operational. LPA observed the left side back burner of the stove would not light. Toxins/ Sharps: LPA observed knives and sharp objects are kept locked in a kitchen drawer. Chemicals and cleaning supplies are kept locked a closet. Water Temperature: Hot water measured 111.2. to 113.9 degrees Fahrenheit in resident bathrooms.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 XIV
FACILITY NUMBER: 306006243
VISIT DATE: 12/16/2022
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Medications, First-Aid Kit & Book: First aid kit contained all the required items. Medication is stored and locked in a kitchen cabinet. Client & Staff File: Records stored in the hall closet. Reading Material, Games, and Equipment: Activities to include outings in the community, arts and crafts and games. Facility has a TV for viewing and reading material. Backyard: LPA observed a clean backyard with ample shaded seating for clients. Both exit gates are latched and operational. No bodies of water observed. No obstacles or hazards observed in the backyard. Fire Clearance: Approved by Orange County Fire Authority inspector Andrew Amante on 10/25/2022. Fire clearance approved for 6 non-ambulatory residents. Delayed egress not approved.

The following items are to be corrected by Applicant by 12/23/2022 to complete the pre-licensing inspection.

- Garage door must lock from the garage side or made inaccessible to residents.
- Admission agreement or a sign stating the Admission agreement is available for review upon request me be posted.
- Rights of resident council must be posted.
- A sign stating in an emergency call 911 and listing the numbers for local law enforcement and fire department. - Facility Theft/Loss policy must be posted.
- Left side back burner of the stove must be repaired so it can light unassisted.

Applicant to contact LPA when corrections have been completed.

Component III waived during the visit, applicant is a Licensee/Administrator of other RCFEs that are in substantial compliance.

Applicant was informed that the final approval will be granted by the Central Applications Bureau in Sacramento after the pre-licensing inspection has been completed. 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: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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