197609022-3-10-2026-31-AS-MGFS-DSCVB3-20260320161650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/10/2026
Date Signed: 03/10/2026 05:37:16 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
02/11/2026 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260211093558

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: 78	DATE:	03/10/2026
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Tanya Quezada - Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff gave the wrong medication to resident in care
Staff did not ensure that residents' nursing care needs were performed by an appropriately skilled professional

INVESTIGATION FINDINGS:

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On 03/10/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit to investigate the allegation(s) above. LPA met with Tanya Quezada - Executive Director and disclosed the reason for the visit.

The initial complaint investigation was conducted by LPA Nadia Shahbazian on 02/17/2026 and pertinent documents were gathered, including records for Resident 1 (R1) and (R2). LPA conducted interviews with the Administrator, (5) staff members and (8) residents.

Regarding the allegation: Staff gave the wrong medication to resident in care. It is alleged that R1 was given medication intended for another resident because they do not verify the residents information.
Interviews with Administrator revealed that R1 was not given medications for another resident. LPA interviewed R2, who revealed that they order their own medication and they keep their medication in a locked box in their room. Per physician’s report dated 06/23/2025: R2 is able to manage and store their medications. R2 informed LPA that staff do not handle R2' medications.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

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-20260211093558

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: 03/10/2026

NARRATIVE

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Interviews with medication technicians revealed that medication for each resident is prepared by reviewing the Medication Administration Record (MAR) and resident’s face sheet in the system. Medication cups are filled based on comparing the MAR to medication list, resident’s name, picture and room # to avoid errors. Interview with staff revealed that every day there is a shift change meeting, in which any changes in residents’ medications or conditions are discussed with all care staff and kitchen staff. Interviews with residents revealed that they have never experienced and/or are aware of any medication errors. During the complaint visit, LPA conducted a medication count/review for (8) residents. Medications were counted and compared to MAR and there were no discrepancies encountered.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding the allegation: Staff did not ensure that residents' nursing care needs were performed by an appropriately skilled professional. It is alleged that staff are performing nursing-related tasks such as; conducting body assessments, making clinical decisions regarding resident medications, and performing other nursing tasks.

Based on interviews with the Administrator and care staff, all staff stated they do not make clinical decisions regarding resident’s care or medications. Medication Technicians communicate with resident’s physician and responsible persons, regarding any changes to residents’ condition or medications. In cases of an emergency, staff immediately calls 911 and notifies the responsible party and residents’ physicians. Also, all staff are notified of any changes in residents’ condition. Administrator stated that there are several residents who are receiving home health or hospice care services through licensed companies; these are licensed nurses who provide care to our residents. Administrator added that “our staff are not trained, nor do they provide any “nursing-related care”. LPA’s interviews with Caregivers revealed that some residents take their own showers, but it is the responsibility of the Caregivers to shower residents two times per week. Per caregivers, they always do a visual body check to ensure there are no wounds. Med techs informed LPA that they do perform visual body checks if a resident falls or returned from the hospital. Interviews with (3) residents revealed that they take their own shower. (5) residents stated Caregivers shower them two times a week and they possibly do body checks during showering.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC9099 (FAS) - (06/04)

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