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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 08/27/2025
Date Signed: 08/27/2025 11:33:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
04/22/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250422083808
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: 74DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Tanya Quezada- Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff does not ensure resident’s room is clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint investigation. LPA met Tannya Quezada, Executive Director, and disclosed the reason for the visit. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations.

Allegation: Staff does not ensure resident’s room is clean
It was alleged that facility staff do not clean R1’s room. The complainant stated that R1’s room is cluttered. Interview with R1 revealed that staff come to R1’s room to provide housekeeping services; however, R1 refused. An interview with the Executive Director revealed that R1 does not allow housekeeping staff in his or her room. The Executive Director mentioned that she had worked with R1 decluttering R1’s room; however, R1 would bring additional boxes into the room. LPA observed R1’s room filled with storage boxes, recycling bottles, and stacks of papers. LPA also noted that R1’s bed sheets are not clean and have urine stains.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
04/22/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250422083808

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: 74DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Tanya Quezada- Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff does not serve nutritious meals to resident(s).
Staff does not assist resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint investigation. LPA met Tannya Quezada, Executive Director, and disclosed the reason for the visit. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations.


Allegation: Staff does not serve nutritious meals to resident(s)

It was alleged that the facility's food is unhealthy and not nutritious. The Executive Director denied the allegation and provided copies of the facility’s menu. Interviews with six(6) out of 74 residents denied the allegation. Based on information obtained, the allegation is deemed Unsubstantiated at this time.
(Continue on 9099C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250422083808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 08/27/2025
NARRATIVE
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Allegation: Staff does not assist resident in a timely manner.

It was alleged that facility staff do not assist R1 with R1’s dressing and toileting in a timely manner. Interview with the Executive Director denied the allegation. Interview with 4 residents denied the allegation. LPA had tested the emergency call in R1’s room and other residents room, and the staff were answering within a minute. Based on information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250422083808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 08/27/2025
NARRATIVE
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 Based on interviews and observations, the allegation is deemed substantiated at this time. LPA advised the Executive Director that facility staff must maintain a clean, safe, and sanitary environment for the residents.

Exit interview conducted, citation issued, copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250422083808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by
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Executive director will conducted in service training to all staff regarding the cited section and will provide list of attendees.
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Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5