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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200855
Report Date: 05/12/2026
Date Signed: 05/12/2026 12:07:46 PM

Document Has Been Signed on 05/12/2026 12:07 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/
DIRECTOR:		HOLLY RICEFACILITY TYPE:
740
ADDRESS:435 WEST 8TH STREETTELEPHONE:
3105470090
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY: 202; 202CENSUS: 69DATE:
05/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Holly Rice - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 05/12/26, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. California Department of Social Services (CDSS) met with Holly Rice - Executive Director and the purpose of today's visit was explained. The facility is licensed to serve (202) elderly adults ages 60 and above, of which (78) can be non-ambulatory on 1st and 2nd floor and (62) ambulatory on 3rd floor and (62) ambulatory on 4th floor. The facility has an approved hospice waiver for (10). Approved for delayed egress. Currently the facility has (70) residents.

The facility is a four-story building situated in a commercial district. It consists of the following: (85) resident bedrooms. Each room has its bathroom within the unit. The facility features an activity room, dining area, kitchen, beauty salon, administrative offices, medication room, computer room, library, and an outside patio area.

CDSS and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. CDSS inspected a total of (8) bedrooms and (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be clean and operational, grab bars in place with no mold/mildew in showers. There was an average water temperature at 132.6°F, outside of title 22 regulation, and the room temperature was comfortable which ranged from 71.2°F to 74.3°F. Report continues, please see LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/12/2026
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One deficiency has been cited, please see LIC809-D; a technical violation has been cited, please see LIC9102-AN. Smoke and carbon monoxide detectors were in operable condition.During the visit, CDSS observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/3/24.

A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

Facilities' liability insurance is current and their annual fees have been paid as of 03/09/26.

There has been one (1) deficiency cited during today's visit, please see LIC809-D.

An exit interview was held with Holly Rice - Executive Director and a copy of facilities' appeal rights, one deficiency and this report has been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2026 12:07 PM - It Cannot Be Edited


Created By: Mario Leon On 05/12/2026 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARBOR TERRACE RETIREMENT CENTER OF SAN PEDRO, LLC
FACILITY NUMBER: 198200855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on CDSS [(observation) (record review)], the licensee did not comply with the section cited above in [five] out of [six] [bathrooms] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2026
Plan of Correction
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California Dept. of Social Services (CDSS) and Executive Director (ED) have agreed to repair water boiler and re-test water temperatures throughout the building, on or before the POC due date. Records will be forwarded to CDSS at Mario.Leon@DSS.CA.GOV
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Mario Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
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