198200855-8-13-2022-11-AS-EDAT-CHA2JG-20220813172618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200855
Report Date: 08/13/2022
Date Signed: 08/13/2022 05:26:28 PM

Document Has Been Signed on 08/13/2022 05:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 79	DATE:	08/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Judith Diamond and Laura Rodriquez		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Laura Rodriquez. LPA explained the purpose of today’s visit. The facility is licensed to serve 78 non-ambulatory and 62 ambulatory elderly adults ages 60 and over. The facility is approved for (10) hospice residents. The facility is a four-story structure located in a commercial neighborhood. It consists of the following: (84) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, beauty shop, administrative offices, computer room, library and outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #109; #204; #313; #327, #419 and #427 water temperature, call buttons, and smoke detectors are all in operable condition. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire and Earthquake Drills were observed to be maintained in order and accurate. The last drill conducted was on 07/21/22. Several working landline phones are available on-site. The facility has a current Certificate of Liability Insurance on file. Evaluation Report continues on LIC 809C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 08/13/2022

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INFECTION CONTROL:
LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents and staff COVID vaccinations were conducted for (R1-R7). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD.

A Technical Violation LIC 9102 is issued for resident #7 (R7). (R7) is on hospice and non-ambulatory resident resides on the fourth floor a non-approved Fire Clearance floor. The Department will follow up with Fire Inspection to determine the status of application. The Department may return to the facility to cite the facility for 87202(a)(2).

No Deficiencies were identified during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Laura Rodriquez.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2022

LIC809 (FAS) - (06/04)

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