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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320197
Report Date: 01/07/2026
Date Signed: 01/07/2026 01:32:25 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
06/11/2025 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 11-AS-20250611154001
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: 63DATE:
01/07/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Luz Rose-Administrator TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Resident sustained multiple pressure injuries due to lack of care from staff
Staff did not ensure that resident's hygiene needs were met.
INVESTIGATION FINDINGS:
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On 01/07/2026, At 10:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct interviews and deliver the findings for the allegations listed above. LPA Allen met with Theresa Cruz-Pascual and she was informed of the purpose of the visit.

The investigation consisted of the following:

Interviews with staff members 1-6 (S1-S6) and Residents 1-7 (S1-S7). A review of Resident 1(R1) file which consisted of Marlora Post Acute Rehabilitation Hospital dated 5/10/2025, UCLA-discharge instructions dated 1/15/2023-1/17/2023 that includes Home Health Service Agency Accute Care UCLA Health Inc. Medlife Supply Orders dated 1/5/2023, after visit care dated 11/8/2022, with medication list, Pre-placement appraisal dated 6/10/2022 and 8/30/2022, Needs and service plan dated 8/30/2022, Physicians Report dated 8/30/2022, Admissions agreement dated 8/30/2022, Identification and emergency information dated 10/7/2022, Intra Care Home Health Providers Inc.
Continued....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 3
Control Number 11-AS-20250611154001
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: 01/07/2026
NARRATIVE
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Notes and UCLA internal Medicine & Pediatrics Progress Notes Post-discharge follow-up dated 5/8/2025.

The investigation revealed the following:

Allegation 1: Resident sustained multiple pressure injuries due to lack of care from staff.

On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated Resident 1 (R1) was regularly assisted by staff with care for pressure injuries whenever R1 allowed assistance. Staff also reported that on several occasions, R1 refused and discontinued wound care services provided by Intra Care Home Health Providers Inc.


On 01/07/2026, LPA conducted interviews with Residents 1-7 (R1–R7) and 6 out of 7 residents stated that they have never sustained multiple pressure injuries, either in the past or currently, while at the facility due to lack of staff care. These residents also expressed confidence that if they were to develop pressure injuries, staff would provide appropriate care. LPA attempted to interview R1; however, R1 no longer resides at the facility.



Allegation 2: Staff did not ensure that resident's hygiene needs were met.


On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff stated staff members ensure all residents’ hygiene needs are met, including those of Resident 1 (R1). LPA also reviewed documentation indicating that R1 refused and terminated care services provided by Intra Care Home Health Providers Inc. Additionally,6 out of 6 staff stated R1 was assisted with hygiene needs whenever R1 allowed staff to help.

On 01/07/2026, LPA attempted to interview R1; however, R1 no longer resides at the facility. Residents R2, R3, R4 and R5 stated that they currently do not require assistance with hygiene needs but expressed confidence that staff would assist them if needed. Residents R6 and R7 stated that staff members assist them with hygiene needs as scheduled and/or as needed.

continued...

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250611154001
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: 01/07/2026
NARRATIVE
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LPA reviewed documentation from Intra Care Home Health Providers Inc. and UCLA Internal Medicine & Pediatrics Progress Notes. Post-discharge follow-up dated 05/08/2025 indicating that R1 declined and terminated services from the home health agency. Records also confirmed that residents in care are receiving hygiene assistance from facility staff.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met. Which means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted where this report was discussed and provided to Luz Rose Administrator at the conclusion of the visit with the appeal rights.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3