197609022-4-7-2026-31-AS-MGFS-DTEMGK-20260423093601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 04/07/2026
Date Signed: 04/07/2026 04:44:08 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
04/02/2026 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260402102935

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: 77	DATE:	04/07/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Tanya Quezada - Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 04/07/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced initial
10 day visit to investigate the allegation(s) above. LPA met with Tanya Quezada - Executive Director and disclosed the reason for the visit.

LPA requested copies of staff roster, resident roster and relevant documentation regarding the investigation, including but not limited to records for Resident 1 (R1). From 11:05am to 3:05pm LPA interviewed the Administrator, (10) Staff members, (10) Residents and (1) Witness.

Regarding the allegation: Staff does not safeguard resident's personal belongings. It is alleged that: Over the past six to seven months, an unknown person has entered Resident 1 (R1)'s room and stolen a large number of items. To investigate the allegation above, LPA interviewed Resident 1 (R1) and (9) residents in random. One (1) Resident stated that they had a box of items, including clothing and shoes, taken or perhaps misplaced, when they moved in but they did not notify the Administrator.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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-20260402102935

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: 04/07/2026

NARRATIVE

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Interview with R1 revealed that throughout last year several smaller items, including postage stamps and gift cards were missing but they did not notify the Administrator. One (1) Resident stated that they are aware of another resident whose items, such as clothing, were missing; the resident informed LPA that none of their items have ever been missing and that they trust the staff members. Interview with the Administrator and (8) Staff members revealed that no residents have notified them of any missing items or are aware of anyone entering residents' rooms without permission. One (1) Staff member mentioned that they were notified by a resident that their purchased item was missing but caregiver was able to locate the item in the room. All staff members stated that facility policy is for staff to notify Administrator of any missing items and generally caregivers will be responsible for searching for resident's missing items. Administrator stated that they prepare LIC 621 Client/Resident Personal Property and Valuable report, as part of the Admission Record but some residents decline to have their belongings itemized and yet they sign the LIC 621. Administrator also stated that they remind residents to notify staff of any items of value, purchased after admission, in order for LIC 621 to be updated. Interview with Witness (W1) revealed that they became aware of R1's possible missing items, such as clothing and personal items but did not know the exact value or exact items, therefore did not notify facility management. Based on interviews it was revealed that facility staff are respectful of residents, resident's rights and their belongings, and if known, they will search for or try to replace any missing items.

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 was conducted with and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

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