197609022-8-21-2026-31-AS-MGFS-DXXUT6-20260915155123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 08/21/2026
Date Signed: 08/21/2026 04:49:07 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
08/19/2026 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260819150042

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:	08/21/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nechama Schochet - Business Office Manager		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not ensure that the facility was kept free of mold
Facility is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced 10 day complaint investigation visit to the facility regarding above allegations. LPA met with Nechama Schochet - Business Office Manager and explained purpose of the visit.

LPA requested copies of the staff roster, resident roster. From 1:35pm to 2:15pm, 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 inside and 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: 08/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

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 2

Control Number 31-AS-20260819150042

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: 08/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation: Staff did not ensure that the facility was kept free of mold. It was alleged that
dripping water was noticed near one resident’s door, with patch of what he believed to be mold.
Regrading the allegation: Facility is in disrepair. It was alleged that installment was done but there is still leakage and runoff maybe from the A/C unit.

To investigate the allegations, from 1:35pm to 2:15pm, LPA conducted a physical tour, including common areas, kitchen, dining room, hallways, patio, inside and outside of the building. LPA also visited ten (10) residents rooms in both floors, bathrooms and balconies, including Resident 1 (R1)’s. LPA interviewed seven (7) staff members and nine (9) residents. LPA’s interview with eight (8) residents revealed that none had seen any mold. LPA attempted to interview R1 but R1 did not respond to LPA’s questions. LPA’s interview with six (6) staff revealed no mold was observed. All staff members stated they immediately report any repair issues to the maintenance and work orders get done quickly but they were not aware of any disrepairs throughout the facility. LPA conducted the tour with the Maintenance Director (S1) and interviewed S1, who stated S1 was notified of possible mold and disrepair. S1 attended to R1’s room and surrounding rooms. No mold was found in any rooms or surroundings. What was observed previously by S1 were discolorations due to water run off and algae on the ground floor, underneath R1’s room. The discoloration was already addressed by power washing the wall. In addition S1 had replaced the gutter next to the balcony, had sealed the gutters and had redirected the water drippings to ensure there is no leaks or drippings. S1 stated facility takes any mold or infestations seriously and every step is taken to correct such issues but assured LPA that there are no molds. LPA observed the gutters to be in good condition with no dripping or leaks. There was discoloration observed on the outside wall of the balcony, next to the gutters. LPA did not observe any mold, spots or mold-related patches next to R1’s balcony or on the wall, or any other places throughout the facility. Based on observations and interviews it was revealed that here is no visible mold and facility has taken steps to repair gutters and leaks.

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: 08/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2