198603416-6-23-2023-28-AS-TVAO-CT7NK9-20230627103130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:24:22 PM

Substantiated

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
06/20/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230620091221

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: 143	DATE:	06/23/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kevin Taliaferro		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff are not following proper COVID-19 mitigation guidance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/23/23 regarding the above allegation. Pasadena Department of Public Health joined the visit. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, COVID-19 Pandemic Protocol, Staff #1-3 interviews (S1 – S3), Resident #1- interviews (R6), Witness #1 (W1), Witness #2 (W2) and physical plant tour.

SEE 9099-C for continuation...

Substantiated

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: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230620091221

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: 06/23/2023

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Staff are not following proper COVID-19 mitigation guidance- It is alleged facility staff is not taking appropriate measures to isolate symptomatic residents and staff. LPA Ramirez did not observe signage at entrance of community that limits visitors to essential personnel only as stated in facility mitigation plan. LPA Ramirez and Pasadena Department of Public Health observed facility dining room to be fully open. Per facility mitigation plan, Responding to an Outbreak: Quarantine when greater than 10% of the Resident population becomes ill, or as directed to do so by local and/or state health departments. Close the dining room, bistro, activities, and any other group activities to prevent transmission of illness. The quarantine can be lifted after 48 hours of no new reported illness, or as directed by local or state health departments. LPA Ramirez observed several signs throughout the facility advertising in person social events that were taking place on 6-23-23 at various times and locations throughout the facility. LPA Ramirez observed six (6) kitchen staff not wearing masks while working in kitchen area and while serving residents in dining area. At 10: 15 am, LPA Ramirez observed S2 inside lobby entrance, not wearing a face mask, welcoming two outside vendors into the facility. Pasadena Department of Public Health had to remind S2 to wear a mask due to ongoing outbreak status. During tour, LPA Ramirez observed S1 exiting R5’s room which had signage indicating “STOP DROPLET PRECAUTIOUS”. S1 was observed not wearing gloves and was still wearing mask after exiting R5’s room. LPA Ramirez did not observe S1 was hands or sanitize hands immediately after exiting R5’s room. LPA Ramirez observed four (4) COVID-19 positive resident carts that were stationed outside the residents’ rooms to not have required alcohol-based hand sanitizer, per facility mitigation plan. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview was conducted with Kevin Taliaferro and a copy of this report, 9099-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230620091221

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/24/2023 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) All staff and volunteers shall perform hand hygiene. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee will provide in house training to re-train staff on following facility mitigation plan. Proof of staff attendance is required to clear POC by due date.
	8 9 10 11 12 13 14	Licesee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

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