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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005670
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:58:42 AM

Document Has Been Signed on 12/12/2024 11:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VERONA COURT XIIFACILITY NUMBER:
306005670
ADMINISTRATOR/
DIRECTOR:		ARDA KARDJIAN RN,BSNFACILITY TYPE:
740
ADDRESS:23852 WARDLOW CIRCLETELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 3DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Julie Gorordo, Arda KardjianTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted by entry by caregiving staff after explaining the purpose for the visit. Administrator Julie Gorordo and Arda Kardijian were notified via telephone and later arrived to assist with the inspection. LPAs observed Administrator Arda Kardijian has a valid Administrator certificate which expires on September 19, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) which is licensed for six nonambulatory residents and has a hospice waiver for six. The facility is a single story home with five resident bedrooms, one staff bedroom, three bathrooms, a living room, a dining room, a kitchen, and a two car garage. LPAs, accompanied by Administrators conducted a tour of the physical plant. On today's visit, LPAs observed three residents in care and two care giving staff present. LPAs observed the See Something, Say Something poster (PUB 475) mounted on a closet door by the entryway. LPAs inspected the five resident bedrooms. All resident bedrooms had the required furnishings of a bed, a chest of drawers, a lamp, and a chair. Resident bedrooms are clean and spacious. LPAs inspected resident bathrooms. Bathrooms are clean. Toilets and faucets tested operational. Bathrooms were equipped with grab bars and non-skid floors. Hot water temperature measured 115.9 degrees Fahrenheit. LPAs observed the facility has a minimum two day perishable and seven day nonperishable food supply on hand in the kitchen. LPAs observed kitchen appliances were clean. LPAs observed the five burner electric cook top is operational. Cleaning supplies were observed to be locked under the sink cabinets. Knives were observed to be locked in a kitchen cabinet. LPAs observed a fire extinguisher mounted in the dining room. Fire extinguisher was charged and up to date on service. LPAs observed the facility conducted their last emergency disaster drill on December 10, 2024. LPAs tested the dual smoke/carbon monoxide detectors which tested operational. The door leading to the garage is kept locked and inaccessible to residents. The two car garage is used for storage and laundry. LPAs observed the facility has a three day emergency food and water supply stored in the garage. LPAs, accompanied by the Administrators toured the exterior portion of the facility. No bodies of water observed. LPAs observed a shaded seating area with furniture for resident use. The backyard has one gate and is operational. Continued on LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 XII
FACILITY NUMBER: 306005670
VISIT DATE: 12/12/2024
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The front yard of the facility is undergoing plumbing repairs. The facility has all utilities and is not being impacted by the repairs in the front yard. The area under repair is off limits and poses no risk to the residents. The construction in the backyard is off limits and poses no risks to the residents. LPAs inspected the First Aid Kit which has all the required components. The facility has a internet device which is dedicated for resident use. LPAs inspected three resident records and three staff records. No discrepancies observed. LPAs reviewed three resident medications and medication records. No discrepancies observed. All staff are background cleared and associated to the facility. Based on today's observations, there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Arda Kardjian and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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