197609022-5-7-2026-31-AS-MGFS-DWHVBT-20260731161805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/07/2026
Date Signed: 05/07/2026 03:25:59 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
03/03/2025 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20250303151829

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: 75	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Tannya Quezada- Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident did not receive necessary medical attention.
Staff did not comply with physician’s instructions for medications and care
Facility did not ensure appropriate communications with resident’s responsible person
Staff did not report observed changes in resident’s condition

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mariana Agban, Nadia Shahbazian and Licensing Program Manager (LPM) Mary Flores conducted an unannounced subsequent complaint investigation visit for the above allegations. Licensing team arrived and were greeted by the receptionist and met with the Executive Director and explained the reason for the visit.

On 3/12/25 LPA Agban conducted an initial complaint visit, conducted a tour of the facility, requested pertaining documents, and delivered findings for 1 allegation. On 3/13/25 LPA conducted a subsequent visit and interviewed 7 residents. On 8/7/25 LPA conducted a subsequent visit and delivered findings for 2 allegations. On 5/7/26 LPAs requested copies of pertinent information, which includes LIC 500 and Resident Roster, interview 7 staff and 6 residents.

Regarding the Allegation: Resident did not receive necessary medical attention.
It is alleged that Resident#1(R1) was in pain and facility staff did not provide pain medication for R1. (Continue on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Mariana Agban
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-20250303151829

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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Interviews with 6 staff revealed residents are provided assistance promptly. Interviews with 7 residents revealed they are provided with medical attention as needed. Record reviewed indicated that on 2/13/25, 2/15/25, and 2/16/25 R1 was provided with pain medication per R1’s request, as prescribed by the physician. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation Staff did not comply with physician’s instructions for medications and care.
It is alleged that facility staff failed to discontinue R1’s high blood pressure medication due to low blood pressure concerns and that R1’s prescribed back brace was not provided. LPA reviewed facility records and observed documentation indicating that, on 01/30/2025 at 4:46 PM, facility staff received instructions from R1’s physician to hold R1’s blood pressure medication due to R1’s low blood pressure condition. Additionally, the LPA reviewed R1’s medication list, which indicated that Amlodipine Besylate 5 mg was placed on hold effective 02/11/2025. Regarding the use of back braces, records reviewed confirmed that R1 was using the prescribed back brace. Facility notes indicate that a back brace was received on 2/12/25 and that a back brace was observed on R1 on 2/14/25. The Administrator stated that a Home Health nurse provided training to facility staff regarding proper assistance with the brace. Interviews conducted with 7 residents stated they receive assistance with medications or doctor’s recommendations as prescribed. Interviews conducted with 6 staff revealed that they assisted as the physician prescribed. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding allegation: Facility did not ensure appropriate communication with the resident’s responsible person and Staff did not report observed changes in resident’s condition.
It is alleged that facility staff did not communicate with R1's responsible party regarding R1’s needs and that facility staff did not report observation of R1 being lethargic. Interview with 6 staff stated that responsible parties are always notified regarding any changes in the condition of the residents and or any incidents that occurred. Interview with 7 Residents revealed that staff notifies their responsible parties regarding any change in condition or any incidents that occur. Record review indicated that on multiple occasions, R1's responsible party was notified. Facility’s internal notes review indicated that on October 2, 2024, R1 was observed to be lethargic, facility staff had called paramedics and R1's responsible party. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
Exit interview conducted, a copy of this report signed and delivered.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Mariana Agban
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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