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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:20:58 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
08/03/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230803145006
FACILITY NAME:MORNINGSTAR OF PASADENAFACILITY NUMBER:
198603416
ADMINISTRATOR:TALIAFERRO, KEVINFACILITY TYPE:
740
ADDRESS:951 S. FAIR OAKS AVENUETELEPHONE:
(626) 204-1700
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:310CENSUS: 152DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Kevin TaliaferroTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is not providing reasonable accommodations to resident in care.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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**This is a corrected version of 9099-C dated 8/4/23.**
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/03/23 regarding the above allegations. LPA Ramirez was met by Administrator Kevin Taliaferro and explained the purpose of the visit. Case management Visit- Deficiencies was created on 8/4/23 stemming from this complaint investigation.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 2 interviews(S1 – S2), Resident #1 interview (R1 ), Witness #1-2 interviews (W1 – W2), Copies of Resident #1 (R1): Preplacement Appraisal Information dated 9/26/2019, Identification and Emergency Information form, Admission Agreement, Special Incident Reports (SIR) for R1, and physical plant tour.

See 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230803145006
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: 08/31/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Facility is not providing reasonable accommodations to resident in care. - It is alleged that facility staff failed to provide reasonable accommodation to resident in care. R1 was admitted into the facility on 9/29/2019. Per Physician’s Report, R1 may leave the facility unassisted. Per W1, R1 is cognitive and has never required memory care assistance or accommodations. R1 was temporarily relocated to room# 212 on July 25th, 2023, due to plumbing and other general contracting issues in R1’s original accommodation (room#115). Room# 212 is in the facility Memory Care Unit. Access to the Memory Care Unit is only accessible through key code for both entry and exit. R1 was temporarily accommodated in memory care unit that did not meet R1s individual service needs. Per 87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. Based on interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Facility is in disrepair- It is alleged the facility is in disrepair. On or around July 18th, 2023, room# 115 was experiencing flooding and A/C issues. Water overflowed from kitchen sink on to kitchen counters and carpet area. Maintenance immediately began to soak up water that flooded R1’s carpet. On July 21st, 2023, plumbers came to troubleshoot cause of plumbing issues. According to Administrator Kevin, additional plumbing work and troubleshooting was required and the facility had an appointment for the plumbers to return on July 27, 2023 at 9am. On July 27, 2023, a second water intrusion occurred and water again began to flow up from the kitchen sink. Per R1, “ me and my caregiver had to get out of the room quick because it began to flood more than the last time.” Per 87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are being cited. Exit interview was conducted with Kevin Taliaferro and a copy of this report, 9099-D and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230803145006
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2023
Section Cited
CCR
87468.2(14)
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87468.2(14)
Additional Personal Rights of Residents in Privately Operated Facilities-
To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents.
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Licensee will certify by 8/5/23, plan to meet with R1's family and develop a plan on how R1's needs can be met while R1 is temporarily accommodated in room #212. Plan will include how the facility plans to protect R1 from memory care residents wandering into R1's room.
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This requirement is not met as evidence by:
Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.
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Licensee will send minutes of meeting by 8/11/23 to LPA Ramirez via email.
Type B
08/11/2023
Section Cited
CCR
87303(a)
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87303 Maintanance and Operation.
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee will provide LPA Ramirez will timeline of repairs by 8/11/23.
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This requirement was not met as evidence by:
R1 had flooding in room coming from kitchen sink which caused plumbing issues and flooding.
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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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3