198200855-3-7-2025-11-AS-JHAD-DF4QJN-20250325121300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200855
Report Date: 03/07/2025
Date Signed: 03/07/2025 12:19:23 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
02/22/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250222173003

FACILITY NAME:	HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC		FACILITY NUMBER:	198200855
ADMINISTRATOR:	HOLLY RICE		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:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Holly Rice - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not treat resident with dignity or respect.
Staff did not ensure that resident was adequately fed.
Staff did not offer resident privacy.
Staff mismanaged resident's medication.
Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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On March 7, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent, unannounced complaint visit. The Executive Director Holly Rice greeted the (LPA). The (LPA) explained that the purpose of this visit was to investigate the allegations mentioned above.

The investigation included interviews, collection of records and tour of the facility. Interviews were conducted with staff members #1 to #6 (S1-S6), resident members #1 to -#7 (R1-R7), and witness #1 to #2 (W1-W2). The Department reviewed several documents, including the Facilty Staff Roster, the Resident Roster, Resident #1 (R1)'s Face Sheet; Identification and Emergency Information; Service Plan; Resident Assessment; Preplacement Appraisal Information; Admissions Agreement; Physicians Report; Resident Manual, Medication Administration Records, and other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not treat resident with dignity or respect.

Allegation #3: Staff did not offer resident privacy.

The complaint stated that staff did not treat Resident #1 (R1) with dignity or respect and failed to provide privacy. It is reported (R1) felt disrespected when staff ordered them to leave the dining area for to make room for other group of residents. In addition, it was overheard staff saying, “Let’s go. All you need is a whip.” Furthermore, reports indicated that staff often ignored (R1's) privacy by entering (R1's) room without permission while (R1) was in the restroom.

On March 4, 2025, between 9:35 AM and 3:10 PM, the Department interviewed six staff members, identified as Staff #1 through Staff #6, regarding the accusations. Six (6) out of six (6) could not corroborate the claims made against them. They stated that all residents are treated with dignity, respect, and privacy.

All staff members have completed training in Workplace Sensitivity courses, which include topics such as Resident Rights, Working with Individuals with Physical Disabilities, Cultural Competence, and the Basics of Depression in older adults, among others. (S1) explained that there is a seating chart for dining. Resident #1 (R1) is in Group A and is served first, followed by Group B. (S1 and S4) mentioned for breakfast, lunch and dinner residents are given 45 minutes.

There are 20 tables available for residents, of which four are vacant. (S1 and S4) clearly stated that (R1) has never indicated feeling rushed to complete meals during mealtime. If that is true, special arrangements would be made to let (R1) finish meals at an empty table that is not assigned. Moreover, all six staff members emphasized the importance of giving residents space and privacy. All staff members must knock and announce themselves before entering a resident's room, rather than barging in unannounced.

On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members identified as Resident #1 through Resident #7. Six (6) out of the (7) could not valid this claim. The feedback from (R2 to R7) commendably highlights the staff's exemplary qualities of respect, kindness, and graciousness. Their commitment to creating a positive and supportive environment has greatly improved their living conditions.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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(R1) was interviewed and expressed that living at this facility was generally acceptable and that the staff treated (R1) well. However, (R1) stated that staff occasionally forced residents to leave the dining area like "cattle" to prepare for the next group. (R1) could not recall the incident’s details, staff names, or date. Regarding privacy, (R1) stated the importance of having personal space, noting that staff do respect (R1's) privacy by knocking and announcing their presence before entering the room.

On March 4, 2025, between 3:30 PM and 4:00 PM, the Department interviewed Welbe Health Care Case Manager identified as Witness #1 who is unable to support this claim. (W1) reported (R1) is actively addressing mental health challenges and is attending supportive weekly therapy to effectively navigate through these obstacles.

A review of the facility’s Dining Seating Chart shows that assigned seating has been implemented for Groups A and B. (R1) is part of Group A. Additionally, a review of the Relias Healthcare Workforce staff training confirmed that all staff have completed the mandatory training, including the Workplace Sensitivity courses.

Based on the information gathered, there is not enough evidence to support the allegations mentioned above.

Allegation #2: Staff did not ensure the resident was adequately fed.

The complaint details indicate that the facility staff did not ensure that Resident #1 (R1) received adequate meals. It has been reported that (R1) is often left feeling hungry due to small portion sizes, and when (R1) requests additional servings, the facility staff often provide excuses for not having more food available. Furthermore, when (R1) asks for alternative meal options, the staff fails to fulfill those requests. It is also noted that (R1) is charged $7 for tray service, which staff insist is necessary for (R1).

On March 4, 2025, between 9:35 AM and 3:10 PM, the Department interviewed all six staff members, identified as Staff #1 through Staff #6, regarding the accusations. Six (6) out of the six (6) refuted this claim. Staff members #1, #2, and #4 stated that (R1) is offered three meals each day; nonetheless, (R1) only participates in lunch and dinner. Staff members #1 and #4 confirmed that a copy of the daily activities and menu is given to every resident.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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The menu includes options for breakfast, lunch, and dinner, as well as alternative choices for lunch and dinner. Staff #4 (S4) mentioned that meals are nutritious, featuring balanced portions of protein, fruits, vegetables, and grains. (S4) also noted that (R1) is not on a special diet but prefers the BRAT diet, which consists of easily digestible foods. (S4) explained that (R1) frequently adjusts the daily menu, and these requests are always accommodated made before 10 AM. Additionally, (S4) affirmed that there are no concerns regarding portion sizes, assuring that every resident is always welcome to request second helpings. (S4) mentioned that (R1) receives a prepared sack lunch at no cost during weekly outings with Welbe Health. Both (S2) and (S4) reported that residents occasionally request Tray Service, which incurs a fee of $6. (R1) is escorted to the dining area for meals but sometimes prefers to eat in the room, which requires Tray Service and results to a charge. According to (S1) and (S2), (R1) is aware of this fee, as it is outlined in the Resident Manual provided to all residents and discussed during the Resident Council Meetings.

On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents could not validate the claim in question. They reported that the meals were sufficient in portion sizes, with alternative options available, and that second helpings can be requested. All residents confirmed their understanding of the Tray Service fee, which is outlined in the Resident Manual, or mentioned that staff would be reminded them about this service fee.

(R1) mentioned that the meal portions were small but noted that they could request second helpings if needed. (R1) preferred not to eat breakfast and was aware of the available snacks. (R1) expressed uncertainty about the Tray Service fee, estimating it to be around $5 per tray. Additionally, (R1) indicated to be on a BRAT diet and that the kitchen staff would accommodate (R1's) dietary requests.

(W2) reported that (R1), a former resident of the facility, expressed concerns about the quality of the meals, the adequacy of the services, and the comfort of the seating arrangements. (R1) emphasized the need for improved dining options and more attentive assistance from the staff.

A reviewed the facility's Resident Manual, dated 12/20/23, which mentions meal tray service on page 3. The List of Alternative Options for Lunch and Dinner, dated 09/2024, and the Facility Menu, dated 03/04/25, displayed that the facility provides alternative meal choices and healthy, balanced meals. The Department checked the food inventory, both non-perishable and perishable, and confirmed it met Title 22 Regulations. Additionally, an inspection of lunch portions found that a bowl of beef vegetable soup, a half crab cake on a roll, coleslaw, and vanilla ice cream for dessert appeared to be sufficient.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Allegation #4: Staff mismanaged resident's medication.

It is alleged that Resident #1 (R1) medication is mismanaged by staff. According to the report, (R1’s) were not administered timely. (R1’s) thyroid medications prior to meals but did not administer by staff until around 10 AM. No further details provided for this matter.

On March 4, 2025, between 9:35 AM and 10:10 AM, the Department interviewed med-tech staff identified as Staff #5 (S5) who dispute this claim. (S4) reported that (R1) is prescribed seven medications and three PRN (as needed). (R1) is scheduled to receive Levothyroxine 50MG daily at 10:30 AM. Since (R1) skips breakfast, the medication is given before lunchtime.

On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents claimed to have no issues with medication management. Four (4) out of the seven (7) claimed to self-medicate and handle their own medications.

(R1) reported to received support from staff for medication administration. However, (R1) expressed concerns about experiencing delays in receiving medications on time, although specific details, names, and dates were not provided. In a follow-up statement, (R1) assured that there were no issues regarding (R1’s) management of medications and expressed confidence in the process.

The Department conducted a review of (R1’s) Physician Medication Orders dated March 3, 2025, as well as the Medication Administration Records covering the period from January 21, 2025 to March 03, 2025, and Centrally Stored Medication and Destruction Record LIC 622. This assessment confirmed adherence to prescribed medications and PRN (as needed) directives. The records were organized and showed no mistakes. This indicates the facility is keeping accurate records and managing medications carefully.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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Allegation 5: Staff did not safeguard resident's personal items.

The complaint indicated that the staff failed to protect the personal belongings of Resident #1 (R1). The report indicated that the staff disposed of (R1's) cat carrier without (R1's) consent after the cat was euthanized. No additional details regarding this incident were provided.

On March 4, 2025, between 9:35 AM and 10:20 AM, the Department interviewed three staff members identified as Staff #1, Staff #2, and Staff #3. Three (3) out of the (3) claimed this accusation is false. (S1-S3) reported (R1) relocated to this facility from Brookdale Ocean House in April 2024. (R1) did not have any valuable items to include in a personal inventory. However, (R1) was viewed as a collector of items and resisted parting with possessions. The facility provided furniture for (R1). (R1) moved in with an elderly cat and had to be euthanized due to poor health. (S1) reported that (R1's) room was serviced several times by Western Exterminator Company due to infestations of fleas and roaches. It was recommended that the cat carriage be disposed of, as it contained fleas that had been detected. (S1) stated that (R1) had been informed and agreed to dispose of the item for (R1’s) well-being and health and safety of all residents in care.

On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents reported not having encountered any missing or lost valuables. All residents interviewed asserted that staff members are trustworthy. Furthermore, they emphasized that residents bear the essential responsibility of safeguarding their personal valuables.

In an interview, (R1) stated that who had no valuables (R1) moved in. (R1) claimed that no personal items had gone missing or been taken. However, (R1) mentioned that the cat carriage was disposed of and was not unaware of or had given permission for staff to dispose of it. (R1) made conflicting statements when (R1) mentioned that (S1) described the cat carriage as “gross,” despite (R1) claiming not to know about anything regarding the carriage being disposed of.

On March 4, 2025, between 1:00 PM and 4:00 PM, the Department interviewed witnesses identified as Witness #1 and Witness #2. (W1) mentioned that (R1) is seeking mental health support to cope with a loss, making acceptance difficult. (W2) noted that (R1), a former resident of the facility, experienced considerable emotional distress when parting with numerous personal belongings collected over the years.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20250222173003

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: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC	FACILITY NUMBER: 198200855
	VISIT DATE: 03/07/2025

NARRATIVE

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The Department conducted a review of the pest control service receipts provided by Western Exterminator, dated October 17, 2024, October 25, 2024, and November 6, 2024. This evaluation confirmed that (R1's) room received treatment targeting both flea and roach infestations, ensuring pest management in the living space.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed Unsubstantiated.

An exit interview was conducted with Holly Rice, and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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