197609022-7-2-2025-31-AS-TAGD-DLSPTF-20250923113553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 07/02/2025
Date Signed: 07/02/2025 01:15:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Nadia Shahbazian

COMPLAINT CONTROL NUMBER: 31-AS-20250624115431

FACILITY NAME:	EVERGREEN RETIREMENT		FACILITY NUMBER:	197609022
ADMINISTRATOR:	TANYA QUEZADA		FACILITY TYPE:	740
ADDRESS:	225 NORTH EVERGREEN STREET		TELEPHONE:	(818) 843-8268
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	99	CENSUS: 73	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Tanya Quezada/Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's confidential information

INVESTIGATION FINDINGS:

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On 07/02/25 Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller responded to the facility to conduct an initial 10-Day investigative visit for a complaint received regarding above allegation. LPA & LPM met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit.

At approximately 8:30AM until 11:30AM, LPA and LPM conducted interviews with facility personnel and Resident 1 (R1). LPA/LPM requested copies of the Staff Roster, LIC 500 and copies of the medical documents for R1.

Allegation states that facility staff did not safeguard resident's confidential information. The complainant alleged that prior to midnight on 04/26/25, R1 was transported to hospital via ambulance

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250624115431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 07/02/2025

NARRATIVE

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due to a medical emergency. Upon return of R1 on 04/27/25, R1 observed resident #2 (R2) in the lobby area at the Concierge desk, reading some paperwork that contained confidential information regarding R1. Complainant did not know who was the person who left confidential documents accessible to other residents in the concierge desk area.

The information obtained during the investigation included the following: On 04/26/25, around 10:00 PM, R1 was experiencing a medical emergency and 911 was called. EMS responded to the facility and transported the resident to hospital via ambulance approximately at 10:35PM. On 04/27/25 R1 returned to facility at approximately 2:30AM, transported by family member in a privately owned vehicle. R1 entered the lobby alone and witnessed another resident (R2) at the front concierge area, holding and reading paperwork that was R1's documents prepared for, and provided to the EMS personnel at the time of the 911 call for R1's medical emergency. The documents included the face sheet and medication list for R1.

R1 was unable to confirm who left the documents in the area of the concierge desk. There was no facility personnel assigned to the concierge desk or lobby area during the hours between (approximately) 5:00pm and 8:00am. R1 did not observe anyone else in the area at the time of this incident. R1 spoke to a facility staff on duty at the time and alerted the staff of the incident. R1 was unable to recall the identity of the staff and did not know the name of R2. R1 did not report this incident to the Administrator.

During the visit, the Administrator advised the LPA & LPM that she only became aware of this incident recently, since R1 had not reported the incident to her. The Administrator was alerted to the incident by a third party. Due to the extend of time between the incident and receiving the information, the Administrator was unable to confirm whether the EMS personnel had knowingly or accidentally left the documents behind, when transporting R1, It is the facility policy to provide EMS with the Face Sheet and Medication List when transporting residents for medical emergencies, and it is the expectation that EMS will take the documents with them to the hospital.

At this time there is insufficient evidence to confirm or deny that facility staff left resident's confidential information accessible to unauthorized persons. The allegation is deemed UNSUBSTANTIATED.

Exit interview conducted. Copy of report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

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