197609022-9-10-2026-31-AS-MGFS-DY7V5K-20260923160804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 09/10/2026
Date Signed: 09/10/2026 03:35:25 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
09/03/2026 and conducted by Evaluator Nadia Shahbazian

COMPLAINT CONTROL NUMBER: 31-AS-20260903102947

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: 73	DATE:	09/10/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tanya Quezada-Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not safegarurd resident's personal supplies

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 and documents regarding Resident 1 (R1). From 10:35am to 11:20am, LPA conducted a physical tour, including both floors. No health or safety issues were observed.

From 11:30am-1:45pm, LPA interviewed the Administrator, (7) staff members and (8) residents.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026

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-20260903102947

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: 09/10/2026

NARRATIVE

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Allegation: Staff did not safeguard resident's personal supplies.

It was alleged that: R1's incontinence supplies consistently go missing. LPA interviewed two (2) witnesses who stated they are aware that incontinence supplies (including pull ups, wet wipes and bladder control pads) are being ordered for R1 but R1 notified them that supplies are missing. Both witnesses stated they have not personally been to R1's room to inspect. LPA conducted an interview with the Administrator revealed that there are several residents who receive packages. Facility does not open packages but simply delivers the items to each resident and resident's personal supplies are never shared. Facility provides incontinence supplies for most residents and the surplus is placed in two storages, in each floor. Interviews with (7) staff revealed that resident's personal supplies are never shared and all supplies are placed in resident rooms. (5) staff stated they were made aware of R1's incontinence items, since R1 notified them but staff assured R1 that the items are in the room and being utilized. (5) staff stated that residents who need toileting care, use approximately 8-10 incontinence diapers/pull ups daily and facility always carries enough supplies. LPA interviewed (8) residents, including R1. (1) resident mentioned that in the past she was missing two jackets but never notified staff. (6) other residents stated they never had any incontinence items or personal item missing and stated staff never shares, mixes or mishandles resident items. LPA interviewed R1 who stated that she has received closed boxes on incontinence care and has asked caregivers to open and organize them. R1 stated they are happy now since personal care and incontinence items are properly stored in their room and R1 has no issues now. LPA visited storage rooms in both floors and did not observe R1's items being stored. Facility uses "Prevail" brand incontinence clothing. R1 uses McKesson brand incontinence products. LPA observed (3) boxes full of McKesson brand incontinence pull ups, pads and wipes inside R1's closet and opened supplies in the closet and underneath the bathroom sink.

Based on the interviews, information obtained and observations, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026

LIC9099 (FAS) - (06/04)

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