<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/03/2025
Date Signed: 10/03/2025 12:08:58 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
06/11/2025 and conducted by Evaluator Nadia Shahbazian
COMPLAINT CONTROL NUMBER: 31-AS-20250611130317
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:TANYA QUEZADAFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 76DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tanya Quezada-Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure facility telephones are in working condition
Staff do not ensure signal system is in working condition
Staff do not provide necessary personal care
Staff do not provide necessary basic services
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/03/25 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint investigation visit to the facility regarding above allegation. LPA met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit.

LPA requested copies of the Staff Roster and Resident Roster. LPA toured the facility; no immediate health and safety issues were observed.

It is alleged: The complainant alleged the facility telephones are not in working condition. Based on interviews with residents in various floors, several residents stated they are not concerned since they own their personal cellular telephones. Residents also stated that there are telephones for residents’ use in activity rooms. In addition, LPA observed working telephones in activity room on the first floor and telephones with sitting area, throughout each floor for residents’ use. Therefore, based on the LPA's observations and interviews with residents, the above allegation is UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20250611130317
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: 10/03/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It is alleged: Signal system is not in working condition. LPA Shahbazian visited 10 resident rooms on various floors randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis and yet, they have the option of calling for assistance by using the signal system. Residents informed LPA that staff come for assistance very quickly. In addition, LPA observed signal systems in each room, next to the beds and in the bathrooms, including bathrooms in common areas. LPA pulled the signal cord in three separate rooms and staff responded within 1-3 minutes. In fact, on one occasion, two separate caregivers arrived within 2 minutes to provide assistance. Therefore, based on the LPA's observations and interviews with residents, the above allegation is UNSUBSTANTIATED at this time.

It is alleged: Staff do not provide personal care. LPA conducted interviews with several caregivers who stated they are assigned to 4-5 residents daily, for assistance. Caregivers stated they bathe residents at least twice a week or more, due to accidents, they check on residents every hour or two hours to assist with any needs such as toileting. Caregivers also informed LPA that they work in conjunction with housekeepers to ensure trash is picked up, rooms and bedding are clean. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis, shower them twice a week or more, clean the rooms and do their laundry. Only one resident stated that sometimes she does not allow caregivers to shower her since “they don’t properly know how” and sometimes my sheets are not changed regularly. Based on the LPA's interviews with staff, personal care is provided timely. Interviews with majority of residents revealed staff are caring and provide personal care; therefore, the above allegation is UNSUBSTANTIATED at this time.

It is alleged: Staff do not provide basic services. LPA conducted interviews with several caregivers and housekeepers who stated are assigned to 4-5 residents daily for assistance. Caregivers stated they bathe residents at least twice a week or more, due to accidents, check on residents every hour or two hours to assist with any needs such as toileting. Housekeepers informed LPA that as part of their daily tasks, they picked up the trash, clean rooms daily and with weekly deep cleaning and change the sheets weekly, or more, due to accidents. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis, shower them twice a week or more, clean the rooms and do their laundry. Only one resident stated that she does not allow staff to clean her room because “they don’t know how and they don’t wash my clothes”. While in the room LPA observed a housekeeper to come and clean the room but resident refused. Based on the LPA's interviews with staff, basic services are provided timely. Interviews with majority of residents revealed staff do provide basic services on daily basis; therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and copy of the report was signed and given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2