198603416-5-9-2023-28-AS-TVAO-CSYL2B-20230620082200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 05/09/2023
Date Signed: 05/09/2023 09:34:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211217140336

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: 140	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kevin Taliaferro		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents sustained injury while in care.
Residents are left in soiled diapers for extended period of time.
Staff does not provide proper meal assistance to resident in care.
Resident was allowed to leave the facility unsupervised.
Residents do not receive proper medication assistance.
Facility is unkempt.
Facility is malodorous.
Resident pendant calls are not answered in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings, stemming from subsequent complaint visit dated 05/05/23 and initial complaint visit conducted by LPA Wesley on 12/22/21. LPA was met by Executive Director Kevin Taliaferro and explained the purpose of the visit.

Allegations:
1) Residents sustained injury while in care. It is alleged Resident #6 (R6) sustained an injury on or around 12/17/21 while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA reviewed R6’s physician’s report, SIRs dated on or around 12/2021 through 01/2022. LPA was unable to find any reported documentation that R6 sustained any injury on or around 12/17/21. Per staff interviewed, if staff sees any injuries or changes in condition, they report it to the Wellness Director or MedTech on duty.

SEE 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20211217140336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/09/2023

NARRATIVE

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2)Staff does not provide proper meal assistance to resident in care. It is alleged staff does not provide residents meal assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA observed several dining room staff assisting residents with meal trays. LPA observed a facility staff member bringing a resident their lunch into their room. LPA observed the staff member place the meal on a rolling tray, towards the resident.

3) Resident was allowed to leave the facility unsupervised. It is alleged R7 was allowed to leave the facility unsupervised. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. R7 file was reviewed, and LPA could not locate any physician orders or other pertinent documentation, stating R7 could not leave the facility unattended.

4) Residents do not receive proper medication assistance. It is alleged staff do not properly give residents medication assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Staff interviewed stated “We hand them the medication in little clear cups and give them water. We can’t force them to swallow them. I have seen some pills on the floor in some rooms, and we tell the administration. I tell the MedTech.”

5) Facility is unkempt. It is alleged staff does not clean residents’ rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 107, 332, and 458. LPA observed rooms to contain the required furnishings and linens. LPA did not observe and deficiencies and health and safety concerns in toured rooms.

6) Facility is malodorous. It is alleged the residents’ rooms have strong smell due to unclean rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room various resident rooms at random and shared living areas. LPA did not smell strong odors of concern.

SEE 9099-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211217140336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/09/2023

NARRATIVE

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8)Resident pendant calls are not answered in a timely manner. It is alleged staff do not answer pendant calls for assistance in a timely manner. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 458 during visit and asked R8 to push “pendant button” at 10:40 am. At 10:46 am, staff came in to check with resident and staff used R8 room phone to ask the front to “clear” call to room 458.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided via email.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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