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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/23/2026
Date Signed: 03/23/2026 04:28:35 PM

Substantiated


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
01/02/2026 and conducted by Evaluator Nadia Shahbazian
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20260102100122
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:TANYA QUEZADAFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 78DATE:
03/23/2026
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tanya Quezada - Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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On 03/23/2026 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 and subsequent complaint investigations were conducted by LPA Nadia Shahbazian on 01/09/2026 and 03/10/2026 pertinent documents were gathered, including records for Resident 1 (R1).

Regarding the allegation: Unlawful eviction. It is alleged that R1 received an eviction notice but there are no reasons why R1 is being evicted. To investigate this allegation LPA conducted interviews with the Administrator, (5) staff members, R1 and (7) residents. Based on interviews with the Administrator and (4) staff, it was revealed that R1 had multiple behavioral outbursts in the past. Several of the outbursts, involved residents and staff.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20260102100122
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: 03/23/2026
NARRATIVE
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Interviews with (3) residents revealed them to be aware of R1’s behavioral issues. Two (2) of the residents stated R1 had disruptive behavior towards them or other residents. LPA interviewed R1 who stated to have been given an eviction notice. However, R1 does not know the reason for the eviction as the notice does not state it. On 12/29/2025, R1 was provided with a 30-day eviction notice with another resident’s name, listed in error. On 01/14/2026, a revised 30-day eviction notice was provided to R1, with correct resident’s name. Based on review of the eviction notice dated 01/14/2026, the reason of the eviction is listed as not following the “Good Neighbor Policy”: To turn down sounds on radios and television after 9:00pm. In addition, residents must treat other residents and staff with respect and must not be disruptive. The 30-day eviction notice does not include details with dates and incidents of R1’s disruptive behavior. Per R1’s Resident Assessment dated 09/15/2025 and Service Plan dated 10/01/2025, no recent behavioral expressions/health status were observed. On five (5) separate occasions, dated 09/26/2024, 08/27/2025, 09/22/2025, 11/05/2025 and 12/18/2025, LIC 624 - Unusual Incident/Injury Reports (UIR)s, were provided to LPA, which list R1's aggressive or disruptive behaviors towards residents and staff. Although R1 had disruptive behaviors, the 30-day eviction notice failed to provide specific information regarding the incidents and facility staff did not ensure to properly re-assess R1 to prevent such behaviors. Administrator stated that a reassessment was requested for R1 and a new eviction notice may be provided to R1 in the future.

Based on interviews with facility personnel and record review, there is sufficient evidence to prove the alleged allegation did occur, therefore the allegation is SUBSTANTIATED.

LIC9099-D with citation and Appeal Rights were provided.

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: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20260102100122
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2026
Section Cited
CCR
03/23/2026
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Eviction Procedures: 87224 (d) - The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
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Administrator has allowed R1 to stay in the facility, since R1 was placed on notice and has not had behavioral outbursts recently. Staff will continue to provide assistance to R1 for behaviors and update the Appraisal/Needs and Care plan.
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Based on interviews and record review, facility did not comply with providing R1 with an lawful eviction notice with specific reasons/dates, which poses/posed an immediate health, safety to persons in care
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Administrator may submit a new eviction notice, along with behavioral reassessement, in the future. POC cleared during today's visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3