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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 09/15/2021
Date Signed: 09/17/2021 08:57:45 AM

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 PASADENAFACILITY NUMBER:
198603416
ADMINISTRATOR:TALIAFERRO, KEVINFACILITY TYPE:
740
ADDRESS:951 S. FAIR OAKS AVENUETELEPHONE:
(407) 999-2400
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:310CENSUS: 102DATE:
09/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Kevin Taliferro, Executive DirectorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the Pre-licensing visit with Executive Director, Kevin Taliaferro and Wellness Director, Rhonda Guzman. The initial Pre-licensing inspection was conducted on 9/9/2021 and which all residents' rooms were inspected on that date.

The fire clearance has been approved for a capacity of 310 residents, which 285 may be non-ambulatory and 25 may be bedridden. The facility has an approved hospice waiver for 30 residents. There are no rooms set aside for bedridden residents. Residents that become bedridden remain in their suite. There are currently 102 residents residing at the facility.

Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are available in the hallways and by the elevators. The menu is posted in the kitchen and also given to the residents in their rooms weekly. The fire extinguishers were last inspected on 5/7/21.

Smoke Detectors: The facility has smoke/carbon monoxide combo detectors in each of the resident rooms.

Appliances: All appliances in the facility are in good repair. The laundry equipment on each floor are operable.

Medications, First Aid Kit & Book: Medications are stored and locked in the Wellness Office located on the 4th floor. LPA Chan randomly selected 12 residents' medication logs to review and all medications are being administered as prescribed. The first aid kit contains all the required supplies along with the current first aid manual which are located in the Wellness Office.

(LIC9099C)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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: 09/15/2021
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The facility had submitted proof of corrections to correct the hot water temperature, freezer and refrigerator temperature deficiencies which was issued on 9/9/21.

Component III: LPA Chan conducted the component III during today's visit to provide information on how to operate the facility within substantial compliance.

Pre-Licensing is complete and this facility has no deficiencies.

An exit interview was conducted and this report has been provided to the Executive Director.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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