374603715-5-16-2024-08-AS-DPEA-D5BLA6-20240516083433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603715
Report Date: 05/15/2024
Date Signed: 05/16/2024 08:34:41 AM

Document Has Been Signed on 05/16/2024 08:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	HARBORVIEW SENIOR ASSISTED LIVING		FACILITY NUMBER:	374603715
ADMINISTRATOR:	SETTINERI, JEFFREY		FACILITY TYPE:	740
ADDRESS:	2360 ALBATROSS STREET		TELEPHONE:	(619) 233-8382
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	30	CENSUS: 25	DATE:	05/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jeffrey Settineri, Administrator & Genoveva Guerrero, Manager		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Daniel Pena, Licensing Program Analyst (LPA) conducted an unannounced annual one year required inspection. LPA was greeted by Office Assistant, Gladys Vincent. LPA later met with Jeffery Settineri, Administrator and Genoveva Guerrero, Facility Manager. LPA introduced himself, explained the purpose of the inspection, and was allowed entry into the facility. Facility census was twenty-five (25) residents. The facility serves thirty (30) elderly residents; ages 60 years and above; all of whom may be non-ambulatory and five (5) of which may be bedridden. A tour of the facility was conducted inside and out. LPA, accompanied by Mr. Settineri and Ms. Guerrero, conducted a general overall inspection, which included, but was not limited to the following: physical plant, food service, facility administration, medication management, resident and staff records, resident rights, and activities. During today's inspection LPA observed the following: All indoor and outdoor passageways were free from obstructions. All bodies of water were observed to be in compliance with Title 22 regulations. Per Mr. Settineri, there are no firearms or other dangerous weapons stored in the facility. Facility layout is consistent with the Fire Clearance. LPA toured a sample of resident rooms and all had a bed, night stand, dressers, chairs and sufficient lighting available for residents. Licensee provided each resident with clean linen in good repair. All resident rooms had an operating signal system and individual pendants for resident use. The hot water temperature used by residents of the facility were measured to be within Title 22 regulation requirements. The facility had multiple functioning carbon monoxide detectors that met statutory requirements. The facility also had operating smoke detectors that met statutory regulations along with several operable fire extinguishers. The facility was stocked with a two day supply of perishable and seven day supply of nonperishable food items. The kitchen and dining areas were clean, in good repair, and there were no

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HARBORVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374603715
	VISIT DATE: 05/15/2024

NARRATIVE

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observable expired food items. Per Ms. Guerrero, the last fire drill was conducted on May 14, 2024.

LPA was able to verify that physical medications in bubble packs and medication containers were being administered by physician's orders. LPA reviewed staff records and verified that all staff reviewed have the required Personnel Record, Criminal Record Clearance, TB clearance, Health Screening Report, and required training in their file. LPA reviewed resident records and verified that a current Physicians Report, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Record were in each resident's file. LPA conducted a sample of staff interviews which did not raise licensing concerns.

Based on today's inspection, no deficiencies were observed.

An exit interview was conducted, and a copy of this report was provided to Administrator Settineri. Administrator Settineri was provided a copy of their Licensee/Appeal Rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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