Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently clean, sanitary, and compliant in areas such as infection control, medication management, and safety equipment. Several complaint investigations were unsubstantiated, including a recent one on March 7, 2025, where allegations about staff treatment, feeding, privacy, and medication were not supported by evidence. The only serious issue occurred in May 2021, when a complaint investigation substantiated financial abuse by a staff member, resulting in a violation related to residents’ personal rights. Since then, the facility has shown improvement, with the most recent annual inspection on June 6, 2025, finding no deficiencies. No fines or enforcement actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 70
Capacity: 202
Deficiencies: 0
Jun 6, 2025
Visit Reason
The inspection was an unannounced annual required visit to evaluate compliance with licensing requirements using the CARE Inspection Tool.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All inspected areas including bedrooms, bathrooms, kitchen, and safety equipment were in good condition and compliant with regulations. No citations were issued during this visit.
Report Facts
Resident bedrooms inspected: 8
Bathrooms inspected: 8
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Medication Administration Records reviewed: 3
Fire/Disaster Drills last conducted: Sep 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Rice | Executive Director | Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 202
Deficiencies: 0
Mar 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2025-02-22 regarding staff treatment of residents, feeding adequacy, privacy, medication management, and safeguarding of personal items at Harbor Terrace Retirement Center of San Pedro.
Findings
The investigation included interviews with staff, residents, and witnesses, review of records, and facility tour. The Department found insufficient evidence to substantiate any of the allegations, concluding that staff treated residents with dignity and respect, provided adequate meals, maintained privacy, managed medications properly, and safeguarded personal items.
Complaint Details
The complaint included allegations that staff did not treat Resident #1 with dignity or respect, did not offer privacy, failed to ensure adequate feeding, mismanaged medication, and did not safeguard personal items. After thorough investigation including interviews and record reviews, all allegations were deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Facility capacity: 202
Census: 68
Medication count: 7
PRN medications: 3
Tray service fee: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Rice | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 70
Capacity: 202
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with regulations for the Harbor Terrace Retirement Center of San Pedro.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All inspected rooms and safety equipment were in operable condition, infection control practices were followed, and no citations were issued.
Report Facts
Resident bedrooms inspected: 8
Residents served: 202
Non-ambulatory residents: 78
Ambulatory residents: 62
Residents on 4th floor: 62
Hospice waiver: 10
Fire/Disaster Drills: 1
Annual fire clearance date: Aug 10, 2023
Residents' service files reviewed: 4
Staff personnel files reviewed: 4
Medication Administration Records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Holly Rice | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 66
Capacity: 202
Deficiencies: 0
Jul 19, 2023
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with all applicable regulations. No discrepancies or deficiencies were cited during the inspection. The physical plant, records, medication storage, sanitation, safety equipment, and emergency preparedness were all satisfactory.
Report Facts
Resident non-ambulatory capacity: 78
Resident ambulatory capacity: 62
Hospice resident capacity: 10
Resident bedrooms: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Marquez | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 79
Capacity: 202
Deficiencies: 0
Aug 13, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were identified during the inspection visit, though a Technical Violation LIC 9102 was issued for a hospice resident residing on a non-approved Fire Clearance floor.
Report Facts
Licensed capacity: 202
Census: 79
Fire and Earthquake Drill Date: Jul 21, 2022
PPE supply duration: 30
Hospice residents approved: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Rodriquez | Administrator | Met with Licensing Program Analyst during inspection |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection and issued the report |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 202
Deficiencies: 1
May 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation that facility staff was financially abusing a resident.
Findings
The investigation substantiated the allegation that a staff member financially abused Resident #1 by managing their finances without power of attorney, issuing cash payments without receipts, and violating the admission agreement. The facility failed to protect the resident from financial abuse, posing a personal rights risk.
Complaint Details
The complaint was substantiated. The allegation was that facility staff financially abused a resident. The investigation included multiple interviews and record reviews, confirming that staff member S2 managed Resident #1's finances without power of attorney, paid other caregivers in cash without receipts, and the administrator was aware of these actions.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by failure to prevent financial abuse of Resident #1 by staff member S2. | Type B |
Report Facts
Capacity: 202
Census: 68
Deficiency Plan of Correction Due Date: Jun 25, 2021
Checks for cash: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Liner | Administrator | Named in investigation findings and interviews regarding financial abuse |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
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