197609022-8-10-2026-31-AS-MGFS-DX9PFE-20260824111635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 08/10/2026
Date Signed: 08/10/2026 04:34:34 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
08/06/2026 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260806153517

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:	08/10/2026
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tanya Quezada-Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not prevent the spread of bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced 10 day complaint investigation visit to the facility regarding above allegation. LPA met with Tanya Quezada-Executive Director and explained purpose of the visit.

LPA requested copies of the staff roster, resident roster, training records, pest control records and other documents relevant to the investigation. From 1:35pm to 2:00pm, LPA conducted a physical tour, including common areas, kitchen, dining room, hallways and ten (10) rooms on both floors in random. LPA also toured the walkways outside of the facility. No health or safety issues or infestations were observed.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

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-20260806153517

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: 08/10/2026

NARRATIVE

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Regarding the allegation that Staff does not prevent the spread of bed bugs. It was alleged that there are bed bugs in a room on the second floor and two rooms on the third floor but facility are not treating the other two nearby rooms where residents may also have bed bugs. To investigate the allegation, from 2:05pm to 3:45pm, LPA interviewed the Administrator, seven (7) staff members and nine (9) residents. Seven (7) residents stated that the rooms and bathrooms are clean and they have not noticed insects or bedbugs. Two (2) residents stated that they were aware of the bed bugs in one room but facility has contacted a pest control company to address the issue. Of the seven (7) staff interviewed, four (4) stated they were informed of only one room on the third floor, which had bed bugs. LPA interviewed the Executive Director who stated last week on Thursday 08/06/26, they became aware of bed bugs in a shared room on the third floor and immediately called a pest control company the facility uses on a regular basis. The pest control company came the same day and found bed bugs in the bed of one resident, in the shared room. Both residents were moved to another room. Executive Director stated the mattress and bed of the room were destroyed and the room was treated with heat treatment and a new bed/mattress was ordered. In addition, some of the chairs in the activity room were replaced, even though there was no infestation discovered. The pest control company visited rooms in both floors but did not find any infestation in other rooms and they will return to ensure facility is free of pests and bed bugs. During LPA’s visit, all rooms, bedding, furniture inspected were observed to be clean, without infestation; all bedding were clean and mattresses were encased in protector sheets. Based on interviews and records from the professional exterminating company, it was revealed that the facility uses the pest control company on a monthly or bi-monthly basis as general maintenance and they have taken all measures to ensure there is no pest infestation. 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 the report was provided.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

LIC9099 (FAS) - (06/04)

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