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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200855
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:43:34 PM


Document Has Been Signed on 04/23/2024 03:43 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLCFACILITY NUMBER:
198200855
ADMINISTRATOR:LINER, LAURAFACILITY TYPE:
740
ADDRESS:435 WEST 8TH STREETTELEPHONE:
(310) 547-0090
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY:202CENSUS: 70DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Holly Rice-Executive DirectorTIME COMPLETED:
03:45 PM
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On 4/23/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Holly Rice /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (202) elderly adults ages 60 and above, of which (78) non-ambulatory residents on 1st floor and 2nd. (62) ambulatory residents on the 3rd floor and (62) residents on the 4th floor. Facility has an approved hospice waiver for (10).

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, medication room, computer room, libraries and outside patio area.

LPA Iniguez toured the physical plant with Executive Director. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #102, #106, #209, #219, #306, #320, #406 and #422; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 113.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC
FACILITY NUMBER: 198200855
VISIT DATE: 04/23/2024
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LPA Iniguez observed the facility to be claen sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene items were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 01/4/24. Annual fire clearance performed on 8/10/2023. Working landline phones are available on-site. A review of (4) residents' service files (R1-R4) and (4) staff personnel files (S1-S4) were maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and no discrepancies were found.

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. All mandated inspection control posters were posted throughout the facility. Copy of liability insurance will be email to LPA. Facility Annual Fess are Current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Holly Rice /Executive Director.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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