198603416-9-9-2021-28-AS-CDCN-C6PW5X-20210909165953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 09/09/2021
Date Signed: 09/09/2021 05:00:10 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 PASADENA		FACILITY NUMBER:	198603416
ADMINISTRATOR:	TALIAFERRO, KEVIN		FACILITY TYPE:	740
ADDRESS:	951 S. FAIR OAKS AVENUE		TELEPHONE:	(407) 999-2400
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY:	310	CENSUS: 102	DATE:	09/09/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kevin Taliaferro, Executive Director		TIME COMPLETED:	05:00 PM

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Licensing Program Analysts (LPAs) Cynthia Chan, Mary Flores, and Jewel Baptiste conducted an announced visit to the facility for the purpose of a prelicensing evaluation. LPAs met with Kevin Taliaferro, Executive Director, and Rhonda Guzman, Wellness Director, who provided assistance with the tour of the physical plant.

An application was submitted to CCLD on 10/28/2020 for a Change of Ownership for a Residential Care Facility for the Elderly for ages 60 years and older. The fire clearance has been approved for a capacity of 310 residents, which 285 may be non-ambulatory and 25 may be bedridden. There are currently 102 residents residing at the facility.

LPAs inspected and observed the following:

Structure: Facility is a 4-story building. The first floor consists of the lobby, Administrative rooms, beauty salon, activity room, dining room, kitchen, common area, commercial laundry room, and 27 resident rooms. The second floor consists of 44 resident rooms, massage room, spa room, family room, Country Kitchen/recreation room, fitness room, Physical therapy room and residential laundry room. The third floor consists of 44 resident rooms, California Kitchen/dining room, game room, residential laundry room, and spa room. The fourth floor consists of 36 resident rooms, Country Kitchen/dining room, family room, medication room and doctor’s office. There are no obstructions to the walkways and/or driveways. There are no pools or bodies of water at the facility.

Bedrooms for Residents: Bedrooms are equipped with a bed, nightstand, recliner, and adequate closet space. There is adequate lighting throughout the room.

Bathrooms: Each resident room has a private bathroom. The bathtub has a grab bar and a non-skid mat.

Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPAs randomly selected 12 residents and 7 staff files to ensure all required forms are in their files. The Administrator's certificate expires on 9/3/2022.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 PASADENA	FACILITY NUMBER: 198603416
	VISIT DATE: 09/09/2021

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Linens & Hygiene supplies: Extra supplies of linens and hygiene were observed in storage rooms.

Food service: Adequate supplies of 2-day perishable and a week of nonperishable are observed. Food in refrigerators were properly covered to avoid contamination. Dishes, cups and flat ware are stored in the kitchen area.

The following items must be corrected and submit the proof of corrections to LPA by 9/10/21.

* The freezer should be maintained at 0 degrees F.

* The Refrigerator should be maintained at 40 degrees F.

* The hot water temperature is measured between 105-120 degree F.

LPA will return to complete the remainder of the inspection and conduct the Component III at a later date.

An exit interview was conducted. A copy of this report was given to Executive Director, Kevin Taliaferro.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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