Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Little Comp Of Mary Subacute Care Ctr during CMS and state inspections, most recent first.
Two CNAs failed to adhere to infection control practices, risking cross-contamination. One CNA did not change PPE between caring for two residents, while another placed clean linen on a soiled cart before attending to a resident. These actions violated the facility's Enhanced Barrier Precautions policy, which mandates consistent PPE use during high-contact care activities.
The facility failed to maintain safe and sanitary food storage and preparation practices. Food items were improperly dated and stored, leading to potential cross-contamination. The ice machine was found with residue, risking contamination, and a bucket of used grease was not cleaned, attracting pests. These deficiencies could lead to foodborne illness among residents.
The facility failed to maintain sanitary conditions in the dumpster area behind the kitchen. One dumpster was overfilled and uncovered, with trash scattered on the ground, including disposable gloves, plastic, paper, and food. This area was near the kitchen's loading and food delivery area. The Food Service Director acknowledged the issue and stated that housekeeping was responsible for cleaning the area, which should be kept clean to prevent pest attraction.
A resident with severe cognitive impairment developed a blood blister on the right big toe, which was not reported to CDPH as required. Despite medical evaluations indicating a possible fracture, staff interviews revealed no prior observations of the injury, and the cause remained unknown. The facility's policy mandates reporting such injuries to rule out abuse, but the incident was not reported, leading to a deficiency.
The facility failed to provide non-pharmacological interventions before administering PRN psychotropic medication to two residents, leading to unnecessary medication use. Both residents received Ativan without prior interventions, and PRN orders exceeded the 14-day limit without reassessment, contrary to facility policy.
A resident experienced significant weight loss due to the facility's failure to honor her cultural food preferences. Despite having a care plan for inadequate oral intake, the resident, who only speaks Korean, was not provided with her preferred foods. Staff interviews confirmed the lack of documentation and provision of cultural foods, leading to inadequate calorie consumption and weight loss.
The facility failed to label and date feeding equipment for three residents, risking infection. A resident's water bag and two residents' tube feeding bottles were not properly labeled or dated, despite their dependence on these for nutrition. Staff acknowledged the oversight, highlighting the importance of changing and labeling feeding equipment every 24 hours to prevent infection.
The facility failed to monitor antibiotic use for two residents whose conditions did not meet infection criteria. One resident was prescribed ampicillin for a UTI without symptoms, and another was given cephalexin for cellulitis without meeting diagnostic criteria. This indicates a lack of adherence to the facility's antibiotic stewardship program.
The facility failed to ensure that a resident's medications were administered by licensed personnel or a trained family member. The resident's family member applied Triad cream and Venelex ointment without documented training or a signed self-administration form, as required by the facility's policy.
Infection Control Breach by CNAs
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two separate incidents involving Certified Nursing Assistants (CNAs). In the first incident, CNA 1 provided care to Patient 2, who was in bed A, and then proceeded to Patient 1's bedside without changing the personal protective equipment (PPE) gown. Although CNA 1 removed gloves and performed hand hygiene, the gown was not changed due to a lapse in judgment when Patient 1 requested assistance. This oversight occurred despite the presence of an Enhanced Barrier Precautions (EBP) sign outside Patient 1's door, indicating the need for gown and glove use during high-contact patient care activities. In the second incident, CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart before proceeding to Patient 1's bedside. This action was taken after CNA 2 was distracted by Patient 2's coughing and went to assist with repositioning to maintain the patient's airway. After providing care to Patient 2, CNA 2 picked up the linen and soiled linen hamper and started towards Patient 1's side of the room, which led to a family member's concern. The facility's policy on Enhanced Barrier Precautions emphasizes the consistent use of PPE during high-contact care activities to prevent the spread of multidrug-resistant organisms, which was not adhered to in these instances.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Several food items in the walk-in refrigerator were not dated for thawing, and a box of pepperoni was stored uncovered in the walk-in freezer. Additionally, expired food items, such as black beans and cooked fruit, were found in the reach-in refrigerator. There was also improper storage of food items, with baked pastries and ready-to-eat turkey deli meat stored next to raw shelled eggs, and raw chicken thighs thawing next to raw ground beef, which could lead to cross-contamination. The ice machine in the facility was not maintained in a sanitary manner, with brown residue found inside the ice bin. This residue could potentially contaminate the ice, posing a risk to residents, staff, and visitors. The Food Service Director (FSD) acknowledged the issue and noted that the ice machine was not clean, and the residue could lead to contamination. A large bucket filled with used cooking grease, fat, and oil was stored under the kitchen counter, and it was not maintained in a clean manner. The bucket was covered with grease and residue, making it sticky to touch, which could attract pests and lead to the growth of microorganisms. The FSD confirmed that the bucket was reused without being cleaned, which could pose a risk of contamination in the kitchen.
Improper Trash Disposal Near Kitchen
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas behind the kitchen in a sanitary manner. During an observation and interview with the Food Service Director (FSD), it was noted that one of the six garbage dumpsters was overfilled with cardboard and trash, and its lid was open. Additionally, there was trash on the ground surrounding the dumpsters, including disposable gloves, plastic, paper, and food. This area was located in the loading and food delivery area next to the kitchen back door. The FSD acknowledged that housekeeping was responsible for cleaning the trash area and agreed that the area was dirty and should be kept clean to prevent attracting pests to the kitchen. The FDA Food Code 2022 requires that receptacles for refuse be kept covered with tight-fitting lids and stored in a manner that makes them inaccessible to insects and rodents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for a resident who developed a blood blister on the right big toe. The resident, who was admitted with diagnoses including respiratory failure, cerebral vascular accident, and had a tracheostomy and gastrostomy tube, was found to have a blood blister by a CNA during a routine cleaning. The resident's Minimum Data Set indicated severely impaired cognitive skills and dependency on staff for various activities, with no prior skin issues noted. The incident was documented in the resident's progress notes, which detailed the discovery of the blood blister and subsequent medical evaluations, including an x-ray that suggested a possible nondisplaced fracture. Despite the documentation and the facility's policy requiring reporting of injuries of unknown origin within 24 hours, the incident was not reported to CDPH. Interviews with staff, including CNAs, LVNs, and the RN, revealed that the injury was not observed during prior assessments, and the cause of the blister remained unknown. The Director of Nursing confirmed that the facility's policy mandates reporting such injuries to rule out abuse or neglect. However, the RN involved did not report the incident, believing it was not abuse, and the House Supervisor was not instructed to report it either. This oversight in reporting the injury of unknown origin to the appropriate authorities constituted a deficiency in the facility's compliance with regulatory requirements.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents, Resident 84 and Resident 96, were free from unnecessary psychotropic medications. For Resident 96, the facility did not provide non-pharmacological interventions before administering Ativan, a psychotropic medication, as needed for anxiety. The medication was administered without prior non-pharmacological interventions, and the PRN order exceeded the 14-day limit without reassessment by a physician. This oversight was confirmed by both a Licensed Vocational Nurse and a Registered Nurse, who acknowledged that the non-pharmacological interventions were documented after the administration of Ativan, contrary to the facility's policy. Resident 96 was admitted with severe cognitive impairment and was dependent on staff for daily activities. The resident had a history of anxiety and was prescribed Ativan to manage symptoms of agitation and restlessness. However, the facility's failure to implement non-pharmacological interventions before administering the medication and the continuation of the PRN order beyond 14 days without physician reassessment placed the resident at risk for adverse consequences. Similarly, Resident 84 was administered Ativan without prior non-pharmacological interventions, and the PRN order was extended beyond the 14-day limit without proper reassessment. Resident 84, who had intact cognition but was dependent on staff for daily activities, was prescribed Ativan for anxiety. The facility's policy required non-pharmacological interventions to be attempted first and PRN orders to be reassessed every 14 days, but these steps were not followed, leading to the unnecessary use of psychotropic medication.
Failure to Honor Cultural Food Preferences Leads to Resident Weight Loss
Penalty
Summary
The facility failed to honor the cultural food preferences of a resident, leading to significant weight loss. The resident, who only speaks Korean and has a history of serious medical conditions including respiratory failure and Moyamoya disease, was admitted with a gastrostomy tube for nutritional supplementation. Despite having a care plan indicating inadequate oral intake and frequent meal refusals, the facility did not document or provide the resident's preferred Korean foods, which contributed to the resident's weight loss. Interviews with staff revealed that the resident's cultural food preferences were not honored, and there was no documentation of these preferences. The resident was offered alternative foods like sandwiches, yogurt, and Jello, which did not align with her cultural preferences. The Registered Dietician admitted to not having met the resident or her family to ascertain her food preferences, despite the facility's policy requiring the RD to ensure cultural food preferences are granted. This oversight resulted in the resident consuming inadequate calories and experiencing weight loss.
Infection Control Lapses in Labeling and Dating of Feeding Equipment
Penalty
Summary
The facility failed to observe proper infection control measures for three residents, leading to potential risks of infection. Resident 29's water bag was not labeled or dated, which is crucial for monitoring and preventing infection. Resident 29 was readmitted with a history of a ruptured cerebral aneurysm and gastroparesis, and was dependent on a gastrostomy tube for nutrition due to dysphagia. The care plan for Resident 29 included monitoring for signs and symptoms of infection, but the lack of labeling on the water bag indicates a lapse in following these precautions. Resident 62's tube feeding bottle was also found to be unlabeled and undated during an observation. Resident 62 was readmitted with a subdural hematoma and chronic respiratory failure, and was comatose and dependent on tube feeding due to dysphagia. The Licensed Vocational Nurse (LVN) responsible for Resident 62 acknowledged the oversight, emphasizing the importance of changing and labeling tube feeding bottles every 24 hours to prevent infection. Similarly, Resident 86's tube feeding bottle was not dated, as confirmed by another LVN. Resident 86 was admitted with encephalopathy, a history of hemicraniectomy, respiratory failure, and dysphagia, and was also dependent on continuous tube feeding. The facility's policy requires labeling and changing of enteral formula containers and administration sets to prevent bacterial growth, but this was not adhered to, as evidenced by the observations and interviews with the staff and the Infection Prevention Nurse.
Inappropriate Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to appropriately address and monitor the use of antibiotics for two residents, Resident 41 and Resident 98, whose conditions did not meet the McGeer criteria for infection. Resident 98 was admitted with diagnoses including respiratory failure and traumatic brain injury. Despite not showing symptoms of a urinary tract infection, Resident 98 was prescribed ampicillin for a UTI, as confirmed by the Infection Preventionist and Registered Nurse. The urine specimen collected did not meet the criteria for a true infection, yet the antibiotic was administered, indicating a lack of adherence to the facility's antibiotic stewardship program. Resident 41, admitted with conditions such as respiratory failure and a cerebral vascular accident, was prescribed cephalexin for cellulitis on the right big toe. The Infection Preventionist confirmed that the resident did not meet the McGeer criteria for cellulitis, as there was no pus or drainage present, and only three signs of infection were observed. Despite this, the antibiotic was administered based on the physician's order, without proper adherence to the criteria set for diagnosing a true infection. The facility's policy promotes the appropriate use of antimicrobials, yet the actions taken in these cases did not align with the policy's guidelines. The Infection Preventionist and Registered Pharmacist acknowledged the importance of using the McGeer criteria to prevent antibiotic resistance, but the facility's practices did not reflect this understanding, leading to the unnecessary administration of antibiotics to both residents.
Failure to Ensure Proper Medication Administration Training
Penalty
Summary
The facility failed to ensure that Patient 1's medications were administered by licensed personnel or a family member who had received proper training. Patient 1, who had chronic respiratory failure and moisture-associated dermatitis on the buttocks, was prescribed Triad cream and Venelex ointment for wound care. However, the Wound Care Nurse (WCN) confirmed that Patient 1's family member had been applying these medications without documented training or a signed self-administration medication form in the patient's record, as required by the facility's policy and procedure (P&P). The facility's P&P mandates that any patient or family member who wishes to self-administer medication must undergo training and sign a form to confirm completion. This form should be documented in the patient's electronic medical record (EMR). The WCN was unable to locate this form for Patient 1, indicating that the required training and documentation were not completed. This oversight had the potential to result in medication errors and ineffective treatment of Patient 1's wound, potentially delaying healing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Pedro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Post-acute Care Center | 0 mi | — | 33 | 0 |
| Los Palos Post-acute Care Center | 0 mi | — | 4 | 0 |
| Palos Verdes Health Care Center | 3.1 mi | — | 24 | 0 |
| Lomita Post-acute Care Center | 4.2 mi | — | 29 | 0 |
| Torrance Memorial Med Ctr Snf/dp | 5.4 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.