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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 10/03/2025
Date Signed: 10/03/2025 02:16:41 PM

Document Has Been Signed on 10/03/2025 02:16 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MORNINGSTAR OF PASADENAFACILITY NUMBER:
198603416
ADMINISTRATOR/
DIRECTOR:		TALIAFERRO, KEVINFACILITY TYPE:
740
ADDRESS:951 S. FAIR OAKS AVENUETELEPHONE:
(626) 204-1700
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 310CENSUS: 151DATE:
10/03/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Kevin Taliafero - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced Case Management -Annual Continuation visit at the facility to continue annual visit initiated on 9/19/25 using the CARE tools. LPA met with Kevin Taliafero and explained the reason for the visit.

The following domains were completed during this visit:
Personnel Records/Staff Training: LPA reviewed 10 staff files. Files were available for review, Files include; TB clearance, health screening, background clearance, personnel record, and training. Five staff were interviewed.
Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in medication room and in the dementia unit. LPA reviewed medication for 10 residents. A log for PRN/Narcotics medication was observed. Resident #6(R6) had clotrimazole 1% cream out of original container without pharmacy label.
Resident Records/Incident Reports: LPA reviewed 10 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal. Appraisal for R4 was last done on 6/26/23, Resident #5(R5) was last done on 4/16/24, R6 was last done in 8/14/23, Resident #9(R9) pre-appraisal was done in 3/3/19. Five residents were interviewed.
Residents with Special Health Needs Facility: Facility is serving 5 residents on hospice. Two hospices plans were reviewed. Facility does not have bodies of water. Dementia unit residents do not have access to knives/sharps, chemicals or medications. A delay egress system was observed and tested in the dementia unit.
Deficiencies noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/03/2025 02:16 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/03/2025 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MORNINGSTAR OF PASADENA
FACILITY NUMBER: 198603416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 10 residents, R6 had a as needed prescribed medication out of original container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Administrator will request a refill for the medication and ensure all medications are maintained in their original container with prescription label will provide training to staff and will submit a copy of training and picture of medication to the department by POC due date 10/10/25.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 10 residents did not have an appraisal done within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Administrator will conduct appraisals for R4,R5,R6, and R9 and submit a copy to the department by POC due date 10/10/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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