197609022-12-19-2025-31-AS-NMAN-DQM7EV-20260123203634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 12/19/2025
Date Signed: 12/19/2025 03:26:07 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
04/08/2025 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20250408085610

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: 74	DATE:	12/19/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Rosie Julinek		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Licensee is financially abusing resident in care.
Licensee did not ensure appropriate communications with resident’s responsible person.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The initial visit was made by LPA Cava and Nadia Shahbazian on 04/15/25. Investigation consisted of interviews with the Executive Director (ED) Tannya Quezada, Staff 1 (S1) and Staff 3 (S3). In addition to interviews, a record review and physical plant inspection to insure the health and safety of the residents was also made.

Licensee is financially abusing resident in care:
In regards to the allegation, it was reported that an unauthorized withdrawal of $1,420 was made from Resident 1’s (R1) account on March 3, 2025, which was not approved and directly violated the terms agreed upon. R1 moved into the facility in the middle of February 2025. It is thought that R1 will be charged $720 for the month of March, and the full amount of $1420 commencing on March 1, 2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

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-20250408085610

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: 12/19/2025

NARRATIVE

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Between (9:00am to 11:00am), interviews were made with the ED and staff. These interviews confirm the following information
· R1 moved into the facility 02/17/25
· The amount for $720 is the pro-rated amount for rent due in February 2025, from 02/17/25 to 02/28/25.
· The full amount of $1420 for rent due will commence on March 1, 2025

Between (11:00am to 12:00pm) LPA conducted a record review of R1’s files. Review of R1’s Admission Agreement confirm the monthly rate of $1420, and R1 being admitted into facility on 02/17/25. A further review from accounting breaks down the transaction from 02/17/25 to 04/05/25. It is as follows:
· 02/17/25 – Amount due $720, prorated rate for twelve (12) days
· 03/01/25 – Rent due for $1420.07
· 04/01/25 – Rent due for $1420.07

In addition to the record review, a physical plant inspection was made between (12:00pm to 2:30pm),

Based on the information obtained, there was insufficient evidence to prove that the Licensee is financially abusing R1. Therefore, the allegation is deemed Unsubstantiated at this time.

Licensee did not ensure appropriate communications with resident’s responsible person.

In regards to the allegation, it was reported that from approximately March 19, 2025 to April 7, 2025, R1’s representative has been trying to get a hold of the ED or any staff available at the facility to resolve R1’s admission agreement and rent due, but the out reach has completely been ignored.

Between (9:00am to 11:00am), interviews were made with the ED and Staff 1 (S1) and Staff 2 (S2). All three deny the allegation. ED and the staff provided email communication between the facility and R1’s representative, to try and resolve the issue pertaining to R1’s rent and admission agreement. Moreover, interviews with the responsible party confirm that there was communication between them and facility staff.

Based on the information obtained, there was insufficient evidence to prove that there was appropriate communication between the Licensee and R1’s Representative. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

LIC9099 (FAS) - (06/04)

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