198200855-5-28-2021-11-AS-JHAD-C7BVBU-20210929161808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200855
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:12:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20200820101751

FACILITY NAME:	HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC		FACILITY NUMBER:	198200855
ADMINISTRATOR:	LINER, LAURA		FACILITY TYPE:	740
ADDRESS:	435 WEST 8TH STREET		TELEPHONE:	(310) 547-0090
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90731
CAPACITY:	202	CENSUS: 68	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator Laura Liner		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff is financially abusing resident

INVESTIGATION FINDINGS:

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On 05/28/2021 around 01:00pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA met with Laura Liner, Administrator and the purpose of the visit was explained.

The Investigation consisted of the following: On 08/24/2020 LPA Calderon interviewed Administrator Laura Liner(S1) and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Physicians Report and Medication list), On 8/20/2020 LPA Calderon interviewed Witness (W1). On 2/01/2021 LPA Calderon interviewed S2-S5 and on 03/19/2021 LPA Calderon interviewed R1–R3. On 09/04/2020 LPA Calderon interviewed Witness 2 (W2) and Resident #1 Family Member (FM1).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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 11-AS-20200820101751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 05/28/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Facility staff is financially abusing resident.
It is alleged on Facility staff is financially abusing resident. On 08/20/2020 LPA Calderon interviewed Witness 1 (W1) who stated that resident was running out of money and that facility was financially abusing the resident. On 08/27/2020 LPA Calderon interviewed Administrator Laura Liner who stated that caregiver S2 worked for the facility part time and was managing R1 finances. The Administrator stated she was aware the CPA in charge of R1s finances passed away around July 2020 and S2 was placed in charge of R1 finances by the CPA due to R1 family not being involved and R1s inability to manage her own finances. On 08/27/2020 LPA Calderon interviewed Witness 2 (W2) who confirmed her father who passed away was taking care of R1 finances, but she did not have power of attorney and gave all financial paperwork including check book, password to R1 on-line account information to S2. On 08/26/2020 LPA Calderon received, and reviewed facility paperwork Needs and Services Plan and Physician report for R1 which confirmed R1 has dementia, but no power of attorney or conservatorship documents were on file. On 09/04/2020 LPA Calderon reviewed RI son letter. On 09/04/2020 LPA Calderon interviewed S2 who confirmed she took care of R1 medical needs, gave her great services and was given control of R1 finances with no power of attorney. S2 confirms she paid other caregivers’ cash without any receipt and that she also issues check to cash and could not support what these checks were for. On 10/20/2020 LPA Calderon received and reviewed bank statement that showed 6 checks for cash and S2 was unable to provide receipts for the cash purchases. S1 was aware that her staff member was not following the admission agreement and was financially abusing R1.

Based on LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC9099D.

A telephonic exit interview was conducted with Administrator Laura Liner.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200820101751

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/25/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee shall submit a plan outlining the steps that will be taken to correct the financial abuse of R1. Licensee shall submit the plan by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed the licensee failed to ensure R1 was not financially abused by S2 while in care. This poses a Personal Rights risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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