197609022-10-3-2025-31-AS-TAGD-DNSTLY-20251126135019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/03/2025
Date Signed: 10/03/2025 12:05:24 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
08/19/2025 and conducted by Evaluator Nadia Shahbazian

COMPLAINT CONTROL NUMBER: 31-AS-20250819144820

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: 76	DATE:	10/03/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tanya Quezada-Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff do not ensure resident rooms are clean and orderly
Staff are not properly mitigating a pest infestation

INVESTIGATION FINDINGS:

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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. At 10:40 LPA toured the facility; no immediate health and safety issues were observed.

It is alleged: Regarding the allegation that rooms are not clean and orderly.
LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that housekeepers clean the rooms, including bathrooms, daily and take out the trash. Only in one of the rooms, LPA observed clutter, although the room was clean. Resident stated that staff do not move the items on the floor but they do clean the floor and the room daily.

Continued on LIC9099C

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)

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Control Number 31-AS-20250819144820

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

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In addition LPA conducted interviews with several housekeepers who stated they are assigned to 4-5 residents' rooms daily. Housekeepers informed LPA that as part of their daily tasks, they pick up the trash, clean rooms daily, with weekly deep cleaning and change the sheets weekly, or more, due to accidents. Based on the LPA's interviews with staff and residents, rooms are cleaned daily. In addition, LPA observed the rooms and bathrooms to be clean; therefore, the above allegation is UNSUBSTANTIATED at this time.

It is alleged: Regarding the allegation that there is a pest infestation. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that the rooms and bathrooms are clean and they have not noticed insects or pests. Only one resident stated that couple of times she noticed “water bugs” in her bathroom, possibly coming from the pipes or opening of the sink. Resident notified the Maintenance Director and mesh coverings were placed in the sink. LPA interviewed the Maintenance Director who showed LPA the purchased mesh covers to install in bathrooms and stated only one resident notified him about the water bug. LPA interviewed the Executive Director who stated there were some “water bugs” in vacant rooms, since they don’t get cleaned as often. Executive Director stated it is facility's policy to fumigate biweekly and provided LPA with invoices from a professional exterminating company, which has been spraying rooms and common areas biweekly. Both the Executive Director and Maintenance Director told LPA that products used for extermination are safe for humans and residents did not get evacuated. Based on the LPA's interviews with staff, facility has taken all measures to ensure there is no pest infestation. In addition, LPA observed the rooms, bathrooms, kitchen and common areas to be clean and without any pests; 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)

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