197609022-1-14-2025-31-AS-TAGD-DFTT6D-20250417142659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:57:19 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.ASC, 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
11/12/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20241112111644

FACILITY NAME:	EVERGREEN RETIREMENT		FACILITY NUMBER:	197609022
ADMINISTRATOR:	ROSIO JULINEK		FACILITY TYPE:	740
ADDRESS:	225 NORTH EVERGREEN STREET		TELEPHONE:	(818) 843-8268
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	99	CENSUS: 70	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Tanya Quezada - ED		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are threatening to evict resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Executive Director Tanya Quezada and explained the reason for the visit.

LPA conducted physical plant tour at 10:25 AM, requested copies of facility documents relevant to the investigation at 10:58 AM and interviewed staff and residents between 11:10 AM to 12:45 PM. It was alleged that Resident #1 (R1) was being forced to move to another room or leave the facility. LPA's record review on 11/20/24 at around 11:00 AM revealed that R1 was issued an eviction letter on 11/12/24 for violating house rules for verbally abusing R1's roommate or Resident #2 (R2). LPA's interview with the former Administrator on 11/20/24 at about 12:15 PM and the Wellness Director today at (R2) at 11:35 AM, revealed that once they received the report on the altercation between R1 and R2 and as no one witnessed the incident as it happened in their own room, they conducted a meeting in their (R1 & R2)’s room to hear both side of their story but R1 became verbally aggressive and called R2 names during the meeting.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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-20241112111644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 01/14/2025

NARRATIVE

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(continued from LIC 9099)

On 11/20/24 interview with R1, R1 denied any wrongdoing nor being verbally abusive to anyone. LPA's interview with R1 today, revealed that R1 is doing okay but maintained any wrongdoing nor verbally abused R2. LPA attempted to interview R2 on 11/20/24 but R2 refused to be interviewed.

Further interview with the former Administrator on 11/20/24 also revealed that they will rescind the eviction letter and give R1 another chance with some condition. LPA's observation during today's visit confirmed that R1 was not evicted and interview with the new Administrator also confirmed that they are not evicting R1 at this time.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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