198603416-10-7-2022-28-AS-BPEA-CJYRMX-20221007130928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 10/07/2022
Date Signed: 10/07/2022 01:09:54 PM

Document Has Been Signed on 10/07/2022 01:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:	(626) 204-1700
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY:	310	CENSUS: 133	DATE:	10/07/2022
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Business Director, Kevin Taliaferro		TIME COMPLETED:	01:15 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	Licensing Program Analysts (LPA) Bennette Pena and LPA Ashley Calderon conducted an annual continuation visit. Upon arriving at the facility, covid-19 screening was performed in the lobby. LPAs met with Executive Business Director, Kevin Taliaferro who assisted with the visit. The Wellness Director, Rhonda Guzman joined the LPAs afterwards. The initial annual visit was conducted by LPA Pena on 9/19/2022. During the initial visit the following was inspected, reviewed and toured: Entire physical plant (2 buildings) outdoor and indoor Outdoor and indoor passageways and exit doors Random residents bedrooms in assisted living and memory care units Smoke and carbon monoxide detectors COVID-19 Infection Control screening protocols and supplies Food supplies Laundry rooms Fire extinguishers CONTINUED ON LIC 809-C......

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MORNINGSTAR OF PASADENA	FACILITY NUMBER: 198603416
	VISIT DATE: 10/07/2022

NARRATIVE

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LPAs Pena and Calderon along with the Administrator and the Wellness Director checked and reviewed the following during this continuation visit:

Hot water temperatures in random residents bedrooms. The hot water readings are as follows:

Phase 1:
Main floor - (Rm 174) - 114.8 deg F
2nd floor - (Rm 236) - 113.5 deg F
3rd floor - (Rm 354) - 114.0 deg F
4th floor - (Rm 458) - 107.5 deg F

Phase 2:
Main floor - (Rm 119) - 115.6 deg F
2nd floor - (Rm 215) - 115.4 deg F
3rd floor - (Rm 317) - 116.2 deg F
4th floor - (Rm 415) - 110.1 deg F

Medication records for eight (8) random residents in both assisted living and memory care units
Eight (8) random Staff records/files
Eight (8) random Resident records/files

The annual required visit is complete. Per Title 22 Regulations, there were no deficiencies observed during the initial and continuation visits.

An exit interview was conducted and a copy of this report was provided to the Executive Business Director, Kevin Talafierro.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

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