197609022-5-7-2026-31-AS-MGFS-DU4Q4J-20260515115023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/07/2026
Date Signed: 05/07/2026 02:40:01 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
04/03/2026 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260403092449

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: 73	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tanya Quezada - Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff retaliated against resident for making a complaint

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)s Nadia Shahbazian, Mariana Agban and Licensing Program Manager (LPM) Mary Flores conducted an unannounced subsequent visit to investigate the allegation(s) above. LPAs/LPM met with Rosie Julinek and explained the reason for the visit.

Initial complaint investigation was conducted by LPA Shahbazian on 04/07/2026. LPA had requested copies of staff roster, resident roster and relevant documentation regarding the investigation and conducted interviews with the Administrator, (7) seven staff members and (9) nine residents. During today's visit on 05/07/2026 LPA conducted interview with an additional resident.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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-20260403092449

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: 05/07/2026

NARRATIVE

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Regarding the allegation: Staff retaliated against resident for making a complaint. It was alleged that a violation letter was issued to a resident in retaliation for reporting a dispute. Interviews with all (7) staff revealed that they all treat residents with respect. (2) out of (9) staff mentioned that residents have spoken to them regarding their concerns, without any fear of retaliation. Administrator stated residents are encouraged to speak with management directly or during the Resident Council Meetings to be able to address concerns. Administrator added that they generally try to assist and resolve residents with their issues. Interview with a resident revealed an incident was brought to the attention of the administrator and resulted in relation with a notice. Interviews with (7) out of (9) residents revealed that they don't have any issues speaking with staff regarding issues and they have not been retaliated against. (1) out of (9) residents stated they are not afraid of retaliation. Document review revealed a violation notice was provided to resident # 1 (R1) on 02/27/26 due to health and safety concerns. LPA observed R1’s room and observed the concerns addressed in the notice.

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. Copy of report provided to Administrator.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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