197609022-7-6-2026-31-AS-TAGD-DVYP9D-20260714110659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 07/06/2026
Date Signed: 07/06/2026 01:40:48 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
04/23/2025 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250423105657

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: 72	DATE:	07/06/2026
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Tannya Quezada, Administrator		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Resident sustained multiple falls due to lack of supervision
Facility staff did not ensure that resident has an appropriate bed
Facility staff did not shower resident
Facility staff did not maintain resident's room clean

INVESTIGATION FINDINGS:

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On 07/06/26, at 8:58am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Tannya Quezada, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 04/23/25, Licensing Program Analysts (LPA)s Mariana Agban and Nadia Shahbazia conducted the initial complaint visit. On 07/06/26, at 10:30am, LPA Saucedo conducted a physical tour, interviewed additional staff and residents.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

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-20250423105657

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: 07/06/2026

NARRATIVE

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Regarding the allegation: Resident sustained multiple falls due to lack of supervision. It is alleged that resident #1 (R1) had two (2) falls since they moved in. Let it be noted that R1 moved in on 04/04/25 and had only one (1) fall on 07/06/25. R1 had one (1) fall on July 06, 2025 that was confirmed by Staff #1 (S1)’s interview with LPA. LPA reviewed the Unusual Incident/Injury Report that was sent to Community Care Licensing Department on 07/09/25. R1 had fallen on 07/06/25 and was sent to the hospital also notification was sent to R1’s Power of Attorney and doctor. LPA could not interview R1 because R1 no longer resided at the facility. LPA obtained R1's admission agreement, Physician's Report and Service Plan. Furthermore, because of R1's fall on 07/06/25, R1 was put on safety checks four (4) times per shift on 07/08/25 for extra precaution. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Facility staff did not ensure that resident has an appropriate bed. It is alleged that that the facility has not provided an appropriate bed for the resident #1 (R1) since they moved in and R1 has been sleeping on a "cot" for 2 weeks. During LPA’s interview with Staff #1 (S1) confirmed that R1 had two (2) beds since their stay at the facility. One (1) was provided by the facility themselves and the other was provided by home health. Let it be noted that R1 was under home health care at the time. LPA could not interview R1 because R1 no longer resided at the facility. During LPA’s physical tour, LPA observed seven (7) random bedrooms that had appropriate beds-beds with bedspreads, mattresses and headboards. LPA interviewed seven (7) residents that confirmed they have always had individual beds and not “cots”. Therefore, based on the record reviews, physical tour and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Facility staff did not shower resident. It is alleged that Resident #1 (R1) did not shower for two (2) weeks. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they confirmed that all residents shower twice a week. LPA could not interview R1 because R1 no longer resided at the facility. LPA interviewed seven (7) residents. Three (3) out of the seven (7) residents that were interviewed need help showering and confirmed they shower twice a week. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

LIC 9099C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250423105657

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: 07/06/2026

NARRATIVE

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Regarding the allegation: Facility staff did not maintain resident's room clean. It Is alleged that Resident #1 (R1)’s room was not cleaned and there was food and trash on the floor. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they confirmed that all resident rooms get cleaned everyday-the trash is taken out daily, basic cleaning and the deep cleaning is done once a week. LPA could not interview R1 because R1 no longer resided at the facility. During LPA’s physical tour, LPA observed seven (7) random rooms and they were clean. LPA interviewed seven (7) residents that confirmed their room is cleaned weekly and the trash is taken out daily. Furthermore, LPA observed one (1) of the housekeepers cleaning the hallway. Therefore, based on the record reviews, physical tour and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

LIC9099 (FAS) - (06/04)

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