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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006243
Report Date: 01/15/2026
Date Signed: 01/15/2026 12:10:59 PM

Document Has Been Signed on 01/15/2026 12:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VERONA COURT XIVFACILITY NUMBER:
306006243
ADMINISTRATOR/
DIRECTOR:		KARDJIAN, ARDAFACILITY TYPE:
740
ADDRESS:23952 HILLHURST DR.TELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 4DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Julie GorordoTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Joseph Alejandre made an announced visit to conduct the required annual inspection. LPA was greeted and granted entry by Staff. LPA met with Assistant Administrator Julie Gorordo and explained the reason for the visit. Administrator Arda Kardjian's Administrator certificate expires on September 18, 2027. The facility is a Resident Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a one story home with six residents bedrooms, one staff room, six bathrooms, a living room, a kitchen, a dining room, and an attached two car garage. LPA and Assistant Administrator Julie Gorordo conducted a tour of the physical plant. LPA observed four residents in care and three caregiving staff present. LPA observed the See Something Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all six residents bedrooms. All resident bedrooms has the required furnishings of, a bed, a chest of drawers, a chair, and a lamp. Resident bedrooms were clean and spacious. LPA inspected resident bathrooms. Resident bathrooms were equipped with grab bars and non-slip mats. Faucets and toilets were operational. Hot water temperature measured between 109.5 and 114.4 degrees Fahrenheit. LPA observed additional linens stored in a hallway closet. LPA observed the facility has a two day perishable and seven day non-perishable food supply on hand. LPA observed the five burner gas stove lights unassisted. LPA observed knives stored in a locked kitchen cabinet. LPA observed chemicals stored under the kitchen sink in a locked cabinet. LPA observed a fire extinguisher mounted on the wall in the kitchen. The fire extinguisher is charged and serviced as of November 4, 2025. LPA tested the smoke/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 2, 2025. The centrally stored medication is stored in a locked cabinet in the dining room. LPA observed the First Aid kit has all the required components. CONTINUED ON 809-C.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 XIV
FACILITY NUMBER: 306006243
VISIT DATE: 01/15/2026
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The door leading to the attached garage is kept locked and inaccessible to residents. The garage is used for laundry and storage. LPA observed the facility has an emergency three day food and water supply stored in the garage. LPA Assistant Administrator Julie Gorordo toured the exterior portion of the facility. LPA observed 2 shaded seating areas, one with a canopy and chairs and one with a table with an umbrella and 4 chairs and for residents to sit outside. The perimeter gates on the Northside and Southside of the facility are self-latching and operational. No bodies of water observed in the backyard. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 4 resident records. No discrepancies observed. LPA reviewed 4 resident medications and medication records. No discrepancies observed. LPA reviewed 3 staff records. LPA observed Staff 2 did not have a completed health screening, Staff 2 did have a negative TB test on file. All staff present at the facility are background cleared and associated to the facility. The facility has an internet device that is dedicated for resident use. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR).

An exit interview was conducted with Assistant Administrator Julie Gorordo and a copy of the report was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/15/2026 12:10 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/15/2026 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VERONA COURT XIV
FACILITY NUMBER: 306006243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed Staff 2 did not have a completed Health Screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Licensee agrees to have Staff 2 complete a health screening documented on the LIC 503 Health Screening Report and to send the completed copy of Staff 2's LIC 503 to the LPA by the due date listed above.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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