197609022-12-15-2025-31-AS-TAGD-DPQSZ3-20251226131829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 12/15/2025
Date Signed: 12/15/2025 01:31:06 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
12/07/2025 and conducted by Evaluator Nadia Shahbazian

COMPLAINT CONTROL NUMBER: 31-AS-20251207212910

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:	12/15/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Tanya Quezada-Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items

INVESTIGATION FINDINGS:

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On 12/15/25 Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Troy Agard visited the facility to conduct an initial 10-Day investigation for the allegation(s) listed above. LPA & LPM met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit.

LPA/LPM requested copies of the Staff Roster/LIC 500, Resident roster and copies of pertinent documents for residents.

At approximately 9:50AM a tour of the facility was conducted and no health hazards were noticed. From 10:05AM until 11:50AM, LPA and LPM conducted interviews with facility personnel and residents, including Resident 1 (R1) and Resident 2 (R2).

Cont on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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-20251207212910

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: 12/15/2025

NARRATIVE

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Regarding the allegation: Staff did not safeguard resident's personal items. It is alleged that a resident's personal belongings are suspected to be stolen by their roommate. To investigate this allegation LPA/LPM conducted interviews with six (6) residents. Four (4) out of six (6) residents stated that they had items missing and notified the staff, who looked for the items. Two (2) residents mentioned that even though staff looked for their items, the items were not located. LPA/LPM interviewed R1 who stated they had three items missing, after moving in but does not know what happened to the belongings and is not clear on when, where or who might have taken said items. During an interview with R2, R2 denied taking any items from R1.
Interview with the staff revealed that R1 and R2 have been living together and have a tendency to argue and accuse each other of taking each other’s belongings. Executive Director has offered to house R1 and R2 in separate rooms but both R1 and R2 did not want to move. Staff mentioned that R1 has a drawer full of items but has not notified staff of any specific missing items. Executive Director stated that she asked residents to inform her anytime they bring any items that is valuable to their attention, so that the items can be added to their property log, in case items are misplaced or destroyed. Interview with staff indicated that when residents notify the staff of any missing items, staff look for the items and try to find it if possible, and/or try to replace them.

Based on interviews, there is not a preponderance of evidence to prove the alleged allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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