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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604266
Report Date: 08/06/2021
Date Signed: 08/06/2021 02:32:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MORNINGSTAR OF PASADENAFACILITY NUMBER:
197604266
ADMINISTRATOR:SUSAN SNYDERFACILITY TYPE:
740
ADDRESS:951 S. FAIR OAKS AVE.TELEPHONE:
(626) 204-1700
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:310CENSUS: 102DATE:
08/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kevin Taliaferro, Executive DirectorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced technical assistance visit at the facility on 8/6/21. LPA met with Kevin Taliaferro, Executive Director, and explained the purpose of the visit. Kevin Grellman, the Pasadena Public Health Department Nurse, also participated in today’s visit.

LPA Chan, Mr. Grellman, and Mr. Taliaferro toured the facility. The following were observed:

* Proper signage were posted at main entrance.


* Upon entry, digital temperature was taken and receptionist conducted screening for symptoms. Hand sanitizer stations are located throughout the facility.
* Visitation area is set up outdoor by the front entrance. The receptionist is supervising the visits and masks are to be worn at all times.
* There are "6 feet markers" on the floors of the commonly used areas. Common areas are currently closed for use and signs are posted to inform residents.
* PPE carts are observed with the following equipment: N95 respirators, goggles, gowns, booties, hand sanitizers. Precaution signage and donning/doffing signage were observed outside of covid-19 positive residents' rooms.
* Maximum capacity signs were posted in the elevators.
* Laundry areas were clean and contained a trash bin with lid.
* Staff break room is located on the 3rd floor with chairs and tables set up with social distancing. All staff on premises were observed wearing a face mask.
* Physical Therapy room had the proper signage and equipment are being sanitized after each use.
* Covid-19 testing is being performed for all staff and residents today.

Additional technical advisory is provided on the LIC9102 form.
An exit interview was conducted. A copy of this report, appeal rights, and the LIC9102 were given to the Executive Director.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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