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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:38:15 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: 72DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tannya Quezada- Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility was not kept at a comfortable temperature
Facility did not safeguard resident’s personal property
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mariana Agban and Nadia Shahbazian conducted an unannounced subsequent complaint visit for the above allegations. LPAs met with Tannya Quezada, Executive Director, and explained the reason for the visit. LPAs conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations.

Allegation: Facility was not kept at a comfortable temperature
It was alleged that R1's room was cold. Interview with 5 out of 72 residents stated that the rooms temperature was not comfortable and that it gets extremely cold. Interview with the Executive Director revealed that the facility has a centralized AC system that can not accommodate every resident. The Executive Director stated that the maintenance director at that time is no longer an employee at the facility. The Executive Director was advised to measure all residents' room temperature and have the AC system adjusted to the appropriate range. The Executive Director was also advised to maintain a daily temperature log in place. Based on the information obtained, the allegation is deemed Substantiated at this time. (Continue on 809C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 6
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: 08/07/2025
NARRATIVE
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Allegation: Facility did not safeguard resident’s personal property.
It was alleged that the facility did not safeguard R1's personal property. LPAs reviewed R1's Resident Personal Property and Valuables form (LIC 621), and it was not complete. Executive director stated that R1's incident happened before she was hired. Executive director was advised to complete all current residents LIC 621. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, citations issued, appeal rights given, and a copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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: 08/07/2025
NARRATIVE
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Allegation: Facility was not kept clean and sanitary
It was alleged that R1's bedsheet had fecal matter. Interviews with 7 out of 72 residents denied the allegation. LPAs conducted a physical plant tour of random rooms, and rooms were observed to be clean and sanitary. Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the finding is Unsubstantiated at this time.

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

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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: 72DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tannya Quezada- Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not respond to requests for assistance timely
Facility was not kept clean and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mariana Agban and Nadia Shahbazian conducted an unannounced subsquent complaint visit for the above allegations. LPAs met with Tannya Quezada- Executive Director and explained the reason for the visit. LPAs conducted a physical plan tour, to ensure health and safety of the residents are protected and in compliance with Title 22 Regulations.

Allegation: Staff did not respond to requests for assistance timely.
It was alleged that R1 had pulled the emergency button four times for staff to come assist R1. It was also alleged that staff do not respond to R2 call button and R2 had waited 2 hours for assistance. Interviews with 6 out of 72 residents denied the allegations. LPAs tested and pulled the emerngecy button in random rooms and staff within a minute responded to the call. Based on interviews the allegation is deemed Unsubstantiated at this time.
(Conitue on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 6
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: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2025
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met.
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Executive Director measure all residents room temperature and have the AC system adjusted to the appropriate range and will maintain daily temperature log. A copy of the log and a picture of adjusted AC system will be sent to LPA by the POC date.
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Based on interviews, the licensee did not comply with the section cited above. Interviews with 5 out of 72 residents stated that room temperature is not comfortable and it gets extremely cold which poses a potential personal rights risk to persons in care.
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Type B
08/14/2025
Section Cited
CCR
87218(1)
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87218 Theft and Loss
(1)The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met.
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Executive Director will complete Resident Personal Property and Valuables form (LIC 621) for all the current residents by the POC date.
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Based on record reviews, the licensee did not comply with the section cited above. R1's Resident Personal Property and Valuables form (LIC 621) and it was not complete. which poses a potential personal rights risk to persons 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.
SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6