<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/16/2025
Date Signed: 10/16/2025 01:53:36 PM

Substantiated


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
04/22/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250422083808
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: 74DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TANYA QUEZADA- Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident’s room is clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 08/27/25 and amended the LIC 9099D. LPA arrived and was greeted by the receptionist, and met with the Executive Director, Tanya Quezada, and explained the reason for the visit. LPA requested copies of LIC 500, the Resident Roster, and other pertinent documents. At 9:45 AM, LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and are in compliance with Title 22 Regulations. During today's visit, LPA interviewed an additional 3 residents, 5 staff members, and the Executive Director. Based on information obtained, the allegation remains Substantiated at this time.

Exit interview conducted, POC is cleared, a copy of this report signed and delivered
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 1