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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006243
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:16:06 AM

Document Has Been Signed on 12/22/2022 09:16 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:
12/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Arda KardjianTIME COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the second pre-licensing visit. LPA was greeted and granted entry by staff. LPA met with applicant Arda Kardjian. LPA and applicant toured the facility. LPA observed the following items have been corrected;

- Garage door now locks from the inside the house making it inaccessible to residents.
- Sign stating the Admission agreement is available for review upon request is posted.
- Rights of resident council sign is posted.
- Emergency 911 sign listing the numbers for local law enforcement and fire department is posted.
- Facility Theft/Loss policy is posted.
- Left side back burner of the stove can light unassisted.

During the visit LPA Alejandre explained the process of this application and also about the post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAB supervisor in Sacramento. Component III was waived during the visit due to applicant is a current licensee for RCFEs and they are in substantial compliance, supervisor approved. Facility meets Title 22 requirements and is ready to be licensed.

An exit interview was conducted and a copy of this report was provided to applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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