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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200855
Report Date: 07/19/2023
Date Signed: 07/19/2023 03:16:11 PM


Document Has Been Signed on 07/19/2023 03:16 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, LLCFACILITY NUMBER:
198200855
ADMINISTRATOR:LINER, LAURAFACILITY TYPE:
740
ADDRESS:435 WEST 8TH STREETTELEPHONE:
(310) 547-0090
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY:202CENSUS: 66DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Sandra MarquezTIME COMPLETED:
02:15 PM
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On 07/19/23 Licensing program analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Sandra Marquez as the purpose of today’s visit was explained. 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 and the current census is 66.

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, med room, computer room, libraries 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. Water temperature, call buttons, and smoke detectors are all in operable condition.

LPA conducted a records review of 4 staff record, 7 resident records and 7 Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.


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 sharp objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers observed around the facility are 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
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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: 07/19/2023
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on 03/02/2023. Working landline phones are available throughout facility. The facility has a current Certificate of Liability Insurance on file. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were cited.

Exit interview conducted with Administrator Sandra Marquez, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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