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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609022
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:04:52 PM

Document Has Been Signed on 07/24/2025 03:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR/
DIRECTOR:		TANYA QUEZADAFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 99CENSUS: 72DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Tanya Quezada - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Nadia Shahbazian and Mariana Agban conducted an unannounced Required One (1) year at this facility today. LPAs met with Tanya Quezada - Executive Director and explained the reason for the visit. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools.

The Residential Care For the Elderly (RCFE) facility is for residents of ages 60 and above. Fire clearance is for 99 ambulatory residents, of which 50 may be non-ambulatory. A hospice waiver for 12 residents is in place with currently only 1 resident is in hospice care. Facility is a three story building consisting of 72 resident rooms, living room, activity room, dining room, kitchen, beauty salon, 2 laundry rooms, underground garage and a courtyard patio areas. The smoke/carbon monoxide detectors are interconnected. There are several fire extinguishers located throughout the facility and last fire inspection was conducted on 03/19/2025. The facility is equipped with emergency pull alarm and fire sprinkler system. There is an elevator with an evacuation chair in the stairway. There is only one entrance being utilized at the facility but there are several exits, in case of emergencies. All required posters were posted at the entrance and the hallways.

A tour of the physical plant was conducted at 9:40 am and the following was noted:

Kitchen: Facility’s kitchen door was observed to be locked and inaccessible to residents. Kitchen floors, counters and work areas were clean and sanitary. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days stored in the walk in refrigerator, walk in freezer, and pantry. Food was properly labeled and stored. Emergency food is kept in a separate locked area, outside of the kitchen. Knives and sharp utensils are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room outside of the kitchen.

(Continued on 809-C)

Eva MillerTELEPHONE: (818) 596-4373
Nadia ShahbazianTELEPHONE: (818) 476-6033
DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 07/24/2025
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Bedrooms: LPA toured multiple resident bedrooms on both floors for health and safety. The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings, bed linens, closets/dresser drawers. All bedrooms were observed to be clean and clear of obstructions.

Bathrooms: There are several bathrooms in the hallway on each floor for staff and residents use. Hot water temperature was measured in two hallway bathrooms, both measured at 106°F. There are private bathrooms in each resident room; all bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats).

Laundry: Facility has two (2) laundry rooms, one (1) in each floor with total of four (4) washers and four (4) dryers. LPAs observed all the machines in functional capacity. Laundry detergents, cleaning agents and other toxins are secured in locked storages outside of the laundry room.

Medications: Facility has a Wellness Room on the second floor, in which all medications are securely locked, inaccessible to residents. Medication and medication records were reviewed for proper documentation. LPAs observed that medication records were consistent with medication administration records. Multiple First Aid kits and the First Aid Manual were observed in the Wellness Room.

Resident records: All records were observed as locked in administration office. A total of seven (7) resident files were reviewed for current physician reports, Needs and Services plans, admission agreements and appraisals. Resident records appeared to be complete and current.

Staff records: All records were observed as locked in administration office. A total of five (5) Staff files were reviewed. Criminal record clearances were present, and staff are associated to this facility. Staff records appear to be complete with current training.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Nadia ShahbazianTELEPHONE: (818) 476-6033
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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