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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603715
Report Date: 07/22/2022
Date Signed: 07/22/2022 01:41:34 PM


Document Has Been Signed on 07/22/2022 01:41 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:HARBORVIEW SENIOR ASSISTED LIVINGFACILITY NUMBER:
374603715
ADMINISTRATOR:SETTINERI, JEFFREYFACILITY TYPE:
740
ADDRESS:2360 ALBATROSS STREETTELEPHONE:
(619) 233-8382
CITY:SAN DIEGOSTATE: CAZIP CODE:
92101
CAPACITY:30CENSUS: 26DATE:
07/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator Jeffrey SettineriTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted a Case Management Visit during an unannounced Complaint Visit. LPA met with Administrator Jeffrey Settineri discussed the purpose of the visit.

During a complaint investigation, LPA discovered, through interviews and record reviews, that Resident 1 (R1) (See LIC 811 confidential names) had a change in behavior as of November 2021 in which R1 would hit Resident 2 (R2) when frustrated. This change in behavior was not documented in residents file, LIC625 or needs and services plan.

Deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted and a copy of the report, Licensee/Appeal Rights (LIC 9058 01/16) and LIC811 were provided to Administrator Jeffrey Settineri.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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Document Has Been Signed on 07/22/2022 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: HARBORVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374603715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited

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Reappraisals- (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition
This requirement is not met as evidence by:
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Based on interviews, and record reviews the licensee did not update the needs and services plan in 1 of 27 residents in care which posed a potential Health, Safety, or Personal Rights risk to persons in care
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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.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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