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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 12/19/2025
Date Signed: 12/22/2025 01:28:24 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
07/30/2025 and conducted by Evaluator Nadia Shahbazian
COMPLAINT CONTROL NUMBER: 31-AS-20250730144554
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:
12/19/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Executive Director -Tanya QuezadaTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted a subsequent visit to the facility to address the allegation listed above. Upon arrival at 10:40 a.m., LPA met with Executive Director -Tanya Quezada and explained the reason for the visit.

On 08/07/2025 the initial complaint visit was conducted by LPAs Shahbazian and Agban, and pertinent documents were gathered, including records for Resident 1 (R1).

During today's visit at approximately 10:50AM a tour of the facility was conducted and no health hazards were noticed.

Cont. on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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 3
Control Number 31-AS-20250730144554
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: 12/19/2025
NARRATIVE
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Regarding the allegation: Staff did not dispense medication as prescribed. It is alleged that on 07/12/2025, approximately at 10:00AM, med tech (S2) erroneously administered a blood pressure medication to the R1 that was not prescribed to R1. To investigate this allegation LPA conducted record review and interviews with five (5) staff members and R1. The medication error was recognized at approximately 12:30PM. S2 attempted to contact R1's primary care doctor (PCP) but there was no response. S2 was advised to contact the paramedics. Paramedics arrived and transported R1 to hospital due to hypotension. R1 later returned to the facility on 7/18/2025. Facility submitted an LIC 624-Unusual Incident/Injury Report (UIR) to LPA regarding the incident. In addition, S1 revealed that due to the error, said S2 was removed from their duties as a med tech and is currently working as a care giver. S1 mentioned that facility has updated their process of medication administration by adding resident's pictures, name and room number on medication cups.

Based on interviews with facility personnel and record review, there is sufficient evidence to prove the alleged allegation did occur, therefore the allegation is SUBSTANTIATED.

Citation, Civil Penalty and Appeal Rights were provided.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250730144554
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2025
Section Cited
CCR
87465(c)(2)
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(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for ... medication ... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met by:
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Administrator removed S2 from their role as a Med Tech and assigned S2 to a Caregiver position. In addition Med Staff were retrained in medication administration process. POC cleared on the date of visit.
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Based on interviews and record review, facility did not comply with physician orders regarding R1's medication, which poses/posed an immediate health, safety to persons in care

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3