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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530337
Report Date: 01/02/2026
Date Signed: 01/02/2026 02:38:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2025 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251119190218
FACILITY NAME:EVERGREEN SENIOR HOME CAREFACILITY NUMBER:
335530337
ADMINISTRATOR:RAHMAN, TAMANNAFACILITY TYPE:
740
ADDRESS:826 PASEO GRANDETELEPHONE:
(909) 636-2945
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:6CENSUS: 6DATE:
01/02/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator - Tamanna RahmanTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Staff are violating residents personal rights.
Staff does not ensure resident's room is free of odor.
Staff denied privacy with resident visitor.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Administrator Tamanna Rahman and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, and facility tour.

For the allegation, staff are violating residents personal rights. During staff interviews, 4 out of 4 staff members stated they have not violated residents’ personal rights. During resident interviews, 2 out of 3 residents stated their personal rights have not been violated. In addition, 1 out of 3 residents was unable to corroborate the allegation.

For the allegation, staff do not ensure resident’s rooms is free of odor. During staff interviews, 4 out of 4 staff members stated they ensure residents’ rooms are kept free of odor. During the facility tour, LPA observed that residents’ rooms were free of odor.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026
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 56-AS-20251119190218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVERGREEN SENIOR HOME CARE
FACILITY NUMBER: 335530337
VISIT DATE: 01/02/2026
NARRATIVE
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For the allegation, staff denied privacy with resident visitors. During staff interviews, 4 out of 4 staff members stated they ensure residents are provided privacy and the ability to have private conversations with their visitors. During resident interviews, 2 out of 3 residents stated they are allowed to have privacy with their visitors. In addition, 1 out of 3 residents was unable to corroborate the allegation.

Based on the evidence found during the investigation, the (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Tamanna Rahman.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2