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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005670
Report Date: 12/14/2022
Date Signed: 12/14/2022 03:22:33 PM

Document Has Been Signed on 12/14/2022 03:22 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 XIIFACILITY NUMBER:
306005670
ADMINISTRATOR:ARDA KARDJIAN RN,BSNFACILITY TYPE:
740
ADDRESS:23852 WARDLOW CIRCLETELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Arda KardjianTIME COMPLETED:
03:42 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted by staff and granted entry. LPA explained the reason for the visit. LPA met with Administrator Arda Kardjian. LPA and Administrator toured the facility. Facility is a single story home with 6 bedrooms (1 bedroom is for caregivers and one of the resident rooms is a shared room), 3 bathrooms, dining room, living room and attached 2 car garage that is being used for storage and kept locked. LPA observed the See Something Say Something Poster (PUB 475) posted next to the front door of the facility. LPA observed the fireplace in the living room is screened. LPA observed all resident bedrooms had the required furnishings and are clean and organized. LPA observed all bathrooms (3) are clean and operational. LPA inspected the kitchen. The kitchen is clean and organized. LPA observed the knives are kept locked in a kitchen drawer. LPA observed the medications are kept locked in a kitchen cabinet. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA toured the garage. The garage is kept locked and inaccessible to residents. The garage is used to store extra food and supplies. LPA and Administrator toured the backyard. There is one exit gate on the East side of the house. The exit is operational. No bodies of water observed. There are 2 separate seating areas in the patio. No obstacles or hazards observed in the backyard. LPA consulted with the Administrator concerning continued Covid-19 mitigation and Provider Information Notices (PINs). 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: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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