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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:51:48 PM

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
03/03/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250303151829
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: 70DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tannya Quezada- Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not enforce house rules regarding no smoking.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mariana Agban, Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller conducted an unannounced initial complaint visit for the above allegation. LPAs arrived and were greeted by the receptionist and met with the Executive Director and explained the reason for the visit. LPAs requested copies of pertinent information, which includes LIC 500 and Resident Roster. LPAs conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. Today's investigation consisted of interviews with 3 out of 70 residents and record review.
Allegation: Facility did not enforce house rules regarding no smoking.
The Reporting Party (RP) alleged noticing a resident sleeping with a lit cigarette in her/his hands. During the physical plant, LPAs observed R2 smoking in R2's bedroom balcony. Executive Director advised R2 to close the door room and smoke in the designated area. The Resident and Care Agreement on pages 21 and 43 indicates that the community is a no-smoking building. Smoking is prohibited in suites and all common areas, both inside and outside the building, including the apartment patios. (Continue on 9099 C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 4
Control Number 31-AS-20250303151829
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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/18/2025
Section Cited
CCR
87405(d)(2)
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Administrator-Qualifications and Duties: The Administrator shall have the knowledge of the requirements for providing care and supervision..The administrator shall also have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
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The administrator will issue letters regarding house rules to prohibit smoking in suites and all common areas, both inside and outside the building. A copy of the letters will be emailed to LPA by the POC date.
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Based on observations and records review the Administrator did non comply with the section sited above by not following the Addmission Agreement regarding the smoking house rules.
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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.
SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20250303151829
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: 03/12/2025
NARRATIVE
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The Executive Director had directed R2 to use the patio as a designated area for smoking. Based on the record review, there's no designated area for smoking. Based on observations and record review, the allegation is deemed Substantiated at this time. Exit interview conducted, citations issued, and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4