197609022-5-14-2025-31-AS-TAGD-DH6UAC-20250530152431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/14/2025
Date Signed: 05/14/2025 01:01:25 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
05/07/2025 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250507145734

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: 75	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Tannya Quezada, Administrator		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Facility coffee maker is in disrepair and staff are not providing hot water to residents for hot tea or coffee.

INVESTIGATION FINDINGS:

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On 05/14/2025, at 09:45am, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA met with Administrator, Tannya Quezada and explained the reason for the visit.

On 05/14/25, LPA asked for the cenus, staff and resident roster. On 05/14/25, at 10:15am, LPA conducted a physical plant tour. LPA interviewed three (3) staff and seven (7) residents and delivered findings.

9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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-20250507145734

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: 05/14/2025

NARRATIVE

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Regarding the allegation: Facility coffee maker is in disrepair and staff are not providing hot water to residents for hot tea or coffee. It is being alleged that the coffee maker was broken and the residents were not being offered other alternatives. LPA interviewed seven (7) residents that were aware that the coffee maker was broken but they also confirmed that there was hot water being provided to them for instant coffee. Three (3) staff confirmed that the coffee maker was broken but repaired as soon as possible and alternatives were being offered to the residents. One (1) staff showed LPA the packets of instant coffee that are given to the residents. During LPA's physical tour, LPA observed a Keurig coffee maker on the second floor that is for resident use. LPA took a picture of the Keurig coffee maker that was properly working and available for resident use. Along side the Keurig coffee maker there was coffee cups, utensils, and non-dairy creamer. LPA also observed another coffee maker and hot water machine for resident use in the Activities Room on the first floor. LPA took a picture of these two (2) machines in the Activities Room. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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