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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005671
Report Date: 11/22/2021
Date Signed: 11/22/2021 03:16:22 PM

Document Has Been Signed on 11/22/2021 03:16 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 XIIIFACILITY NUMBER:
306005671
ADMINISTRATOR:ARDA KARDJIAN RN, BSNFACILITY TYPE:
740
ADDRESS:23851 WARDLOW CIRCLETELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Arda KardjianTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Jerome Haley and Joseph Alejandre met with Administrator (AD) Arda Kardjian for the purpose of conducting the required Annual “Mitigation” Inspection. LPAs were greeted and granted entry to the facility by Administrator Kardjian. LPAs toured the facility with the AD to verify the facility is still vacant as last reported to LPA Alejandre. LPAs toured the second story of the facility and it's for staff use only and off limits to residents. The facility has all utilities, and all bedrooms have the required furnishings for residents. The facility is ready and in proper condition to accept residents. Facility is recently licensed but is is vacant at this time. AD Kardjian stated that she would notify LPA when new residents move to the facility. Facility has a mitigation plan that has been approved. At this time there are no deficiencies being cited. An exit interview was conducted and a copy of this report was provided to AD Arda Kardjian.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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