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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320197
Report Date: 05/19/2025
Date Signed: 05/19/2025 02:02:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2024 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240813131630
FACILITY NAME:PLAZA AT WESTWOOD, THEFACILITY NUMBER:
198320197
ADMINISTRATOR:LUZ EMMA ROSEFACILITY TYPE:
740
ADDRESS:2228 WESTWOOD BLVDTELEPHONE:
(310) 475-8861
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:136CENSUS: 65DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Teresa Pascual, Wellness Director.TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff retaliate against residents in care.
Staff yell at resident(s) in care.
Facility is in disrepair.
Staff verbally abuse resident(s) in care.
Staff harass resident(s) in care.
Staff discriminate against resident in care.
Staff steal resident(s) personal belongings while in care.
INVESTIGATION FINDINGS:
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On 05/19/2025, at 10:39 am, Licensing Program Analyst (LPA) Zina Brown conducted a complaint visit to the facility and was greeted by Teresa Pascual, Wellness Director. The department explained the purpose of this visit is to deliver findings for the allegations mentioned above.

The investigation consisted of the following:
An initial complaint visit was completed by the department on 08/21/2024, during the visit the department interviewed staff and obtained facility files. A subsequent visit was completed by the department on 11/04/2024 and the department interviewed staff (S1-S5) and residents (R1-R6). The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm. The department received the following: Resident Roster (Dated: 11/04/2024), Staff Roster (Dated: No Date), Maintenance log (Dated: Various Dates), and Theft and Loss Policy (Dated: No Date) were obtained from the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2024 and conducted by Evaluator Zina Brown
COMPLAINT CONTROL NUMBER: 11-AS-20240813131630

FACILITY NAME:PLAZA AT WESTWOOD, THEFACILITY NUMBER:
198320197
ADMINISTRATOR:LUZ EMMA ROSEFACILITY TYPE:
740
ADDRESS:2228 WESTWOOD BLVDTELEPHONE:
(310) 475-8861
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:136CENSUS: 65DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Teresa Pascual, Wellness DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Licensee is not ensuring that resident(s) are provided with hot water while in care.
INVESTIGATION FINDINGS:
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On 05/19/2025, at 10:39 am, Licensing Program Analyst (LPA) Zina Brown conducted a complaint visit to the facility and was greeted by Teresa Pascual, Wellness Director. The department explained the purpose of this visit is to deliver findings for the allegations mentioned above.

The investigation consisted of the following:
An initial complaint visit was completed by the department on 08/21/2024, during the visit the department interviewed staff and obtained facility files. A subsequent visit was completed by the department on 11/04/2024 and the department interviewed staff (S1-S5) and residents (R1-R6). The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm. The department received the following: Resident Roster (Dated: 11/04/2024), Staff Roster (Dated: No Date), Maintenance log (Dated: Various Dates), and Theft and Loss Policy (Dated: No Date) were obtained from the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2025
Section Cited
CCR
87303(e)(2)
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Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents shall be...attain a temperature of not less than 105 degree F... and not more than 120 degree F .. This requirement is not meet as evidence by
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The licensee will ensure that maintenance supervisor will inspect the water boiler & will continue to test the water temperature to ensure it is within required range 105F - 120F (per Title 22) throughout all the facility resident rooms 207, 208, 211, 320, and 309, etc.
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Based on interview & observation, LPA checked the water temp in Rooms 207 (101.7F), 208 (99.3F), 211 (98.6F), 320 (104.F) & 309 (96.4F) which is not within required range as documented in Title 22 regulation which poses an Health & Safety risk to persons in care.
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Submit proof of correction to zina.brown@dss.ca.gov by POC due date.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
VISIT DATE: 05/19/2025
NARRATIVE
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Allegation #8 - Licensee is not ensuring that resident(s) are provided with hot water while in care.

On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 3 of 5 staff denied the allegation that Licensee is not ensuring that resident(s) are provided with hot water while in care. Most of the staff stated that they have no knowledge of any issues with the hot water in the facility. While another staff stated that it takes a little while for the water to heat up, but it does.

The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents denied the allegation. Half of the residents interviewed stated that they do not have a problem with getting hot water, while the other half stated that it takes a while for the water to heat up in the facility.

On 05/19/2025 between the hours of 10:52am - 11:50am LPA checked the water temperature in the following resident rooms: Room 225 (108.F), Room 224 (106.2F), Room 215 (106.8F), Room 207(101.7F), Room 208 (99.3F), Room 211 (98.6F), Room 320 (104.F) and Room 309 (96.4F).

Based on LPAs observations and interviews there is sufficient evidence to support the allegation that the Licensee is not ensuring that resident(s) are provided with hot water while in care the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A deficiency has been issued for this allegation.

An exit interview was conducted, and a hard copy of this Complaint Investigation Report with Appeal Rights was provided to Teresa Pascual, Wellness Director.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
VISIT DATE: 05/19/2025
NARRATIVE
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Allegation #1- Staff retaliate against residents in care.

It is alleged that the resident is concerned with retaliation if they were to make a complaint against the facility. It was reported that residents are afraid of reporting and are leaving the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that the Staff retaliate against residents in care. All staff (S1-S5) stated that they have never retaliated against any residents in care and that they try to resolve any issues the residents may have and foster an open-door policy with respect to complaints and other issues in the facility.

The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been retaliated against because they made a complaint and felt comfortable voicing their concerns about issues in the facility without fear of retaliation.

Based on interviews conducted, there is insufficient evidence to support the allegation that the Staff retaliate against residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #2- Staff yell at resident(s) in care.

It is alleged that the staff in the facility yell and scream at residents and make it unbearable to live there. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff yell at resident(s) in care. All staff (S1-S5) stated that they have never yelled at any resident and are unaware of any staff that has yelled at residents. Staff further stated that if residents are upset or uncooperative they get the family involved to diffuse any misunderstandings before it escalates.

The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not experienced being yelled at by the staff. They further state that the staff treats them with dignity and respect.

Based on interviews conducted, there is insufficient evidence to support the allegation that Staff yell at resident(s) in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
VISIT DATE: 05/19/2025
NARRATIVE
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Allegation #3 - Facility is in disrepair.

It is alleged that the facility is in disrepair and there are problems with the water lines. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Facility is in disrepair. All staff (S1-S5) stated that the facility is not in disrepair and that some rooms are in the process of upgrading some of the flooring, repainting rooms, and fixing waterlines in the facility.

The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents denied the allegation. The majority of residents interviewed stated that they believed the facility was not in disrepair and are happy with the way the facility looks.

The department toured the facility and observed that several rooms were being remodeled and new waterlines were purchased and were being installed. The department did not observe the facility to be in disrepair.

Based on observations and interviews conducted, there is insufficient evidence to support the allegation that Facility is in disrepair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
VISIT DATE: 05/19/2025
NARRATIVE
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Allegation #4- Staff verbally abuse resident(s) in care.

It is alleged that the facility staff abuses the residents verbally, while living at the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff verbally abuse resident(s) in care. All staff (S1-S5) stated that they have not verbally abused any of the residents and the facility does not allow staff to treat the residents in such a way. They state that the residents have personal rights and one of those rights are not to be spoken to without respect and never yelling at them.

The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been verbally abused or yelled at by the staff. They further state that the staff has always spoken to them in a respectful manner.

Based on interviews conducted, there is insufficient evidence to support the allegation that Staff verbally abuse resident(s) in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #5- Staff harass resident(s) in care.

On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff harass resident(s) in care. All staff (S1-S5) stated that they have not harassed any resident and are unaware of any other staff that has harassed a resident at the facility. They further state that they have taken personal rights training and harassment of any kind is not accepted at the facility.

The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been harassed by the staff.

Based on interviews conducted, there is insufficient evidence to support the allegation that Staff harass resident(s) in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20240813131630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PLAZA AT WESTWOOD, THE
FACILITY NUMBER: 198320197
VISIT DATE: 05/19/2025
NARRATIVE
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Allegation #6 - Staff discriminate against resident in care.

On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff discriminate against resident in care. All staff (S1-S5) stated that they have no knowledge of anyone discriminating against any resident living at the facility. They further state that no one has reported being harassed to them.

The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been discriminated against by any staff member.

Based on interviews conducted, there is insufficient evidence to support the allegation that Staff discriminate against resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #7- Staff steal resident(s) personal belongings while in care.

It is alleged that the facility staff and caregivers discriminate against the resident in care at the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff steal resident(s) personal belongings while in care. All staff (S1-S5) stated that they have no knowledge of anyone stealing resident’s belongings. They further state that sometimes residents will misplace their items and when they go to investigate the items are found.

The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been a victim of theft in the facility.

Based on interviews conducted, there is insufficient evidence to support the allegation that Staff steal resident(s) personal belongings while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No citations were issued for this complaint.

An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Teresa Pascual, Wellness Director.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8