198603416-8-31-2023-28-AS-KRAZ-CV8TZZ-20230831151111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:11:22 PM

Document Has Been Signed on 08/31/2023 03:11 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: 152	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Kevin Taliaferro		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/31/2023 at 8:25 am. LPA was met by Administrator Taliaferro and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents and is allowed to care for three-hundred ten (310) non-ambulatory residents of which twenty-five (25) may be bedridden residents. The facility currently has an approved hospice waiver for thirty (30) residents. LPA Ramirez requested copies and obtained of Personnel Report (LIC 500) and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 8:31 am and was led by Administrator Taliaferro. The facility is low-rise 4 story building located near a residential area and several retail centers.

Front Lobby: Was clean and well maintained. No hazards were observed. LPA Ramirez observed PPE supply station upon entry to the facility.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. Walk in refrigerator thermostat was observed to read 37 degrees F. LPA Ramirez observed staff preparing lunch at 10:15 am. LPA Ramirez observed staff wearing gloves while handling food. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguishers in this area.

Dining Room: Dining room was observed to be clean and contained plenty of seating. LPA Ramirez observed three (3) servers taking residents orders and bringing out their meal.

Linen/Laundry/Supply Room: Contained plenty linens, towels, and hygiene products.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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: 08/31/2023

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Resident Rooms: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez selected eight (8) resident rooms at random to inspect.

Bathrooms: LPA Ramirez tested water temperature in eight (8) resident bathroom sinks. Water temperatures were within 105- 120 degrees F. Bathrooms were observed to be clean and have required non-slip mats and grab bars in shower and near toilet.

Centrally Stored Medications: LPA Ramirez observed several medications carts to be locked during visit. LPA Ramirez observed med techs dispensing medications during visit.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors LPA Ramirez observed posted Emergency Disaster Plan.

Due to time constraints, LPA Ramirez will return to complete file reviews, conduct staff and resident interviews. No deficiencies are being cited today. Exit interview was conducted Administrator Taliaferro and a copy of this report and appeals rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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