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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:08:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/16/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231016185047
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: 150DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Kevin TaliaferroTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff are not able to adequately care for resident due to resident needing higher level of care.
Resident assaulted other residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Executive Director Kevin Taliaferro.

The investigation consisted of the following: A tour of the facility was conducted. Staff (S1- S6) and residents (R2- R7) were interviewed. Resident (R1) is presently hospitalized and not interviewed. Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Preplacement Appraisal, Resident Appraisals, Physician's Report, Care Plan, Medication Administration Records [MARs Sep. 2023- Oct. 2023], Admission Agreement, incident reports, and resident and staff rosters.

***Narrative continues next page.***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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 2
Control Number 28-AS-20231016185047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2023
NARRATIVE
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Allegation: Staff are not able to adequately care for resident due to resident needing higher level of care. It is alleged that Reflections Memory Care unit staff are are not able to meet the care needs of resident (R1) due to the resident's aggressive behaviors that are a danger to self and others. On 10/12/2023, facility staff called Pasadena Police Department because resident (R1) was exhibiting aggressive verbal and physical behaviors that escalated into the resident attempting to hit another resident and physically injuring staff (S2) by biting staff on the shoulder, kicking, and spitting on staff (S2's) face. A total of four (4) Reflections unit staff responded and assisted during the incident. Staff attempted to redirect resident (R1). However, the resident was combative and displayed aggressive behaviors that posed a danger to others. Based on staff interviews, staff stated that they are able to provide Activities of Daily Living (ADL) care to all residents residing in the Reflections unit, including resident (R1). Nonetheless, resident (R1) has behaviors that do not seem to be controlled with medications or redirection techniques. Per record review, resident (R1) has a diagnosis of Alzheimer's Disease/Dementia with behavioral changes. Reflections Care Plan (9/29/2023) has notation of aggressive behaviors and changes in medications. A total of 6 residents were interviewed, of which only one resident was able to recall the incident. The resident stated that they did not feel resident (R1) requires a higher level of care, because aggression is not atypical to Dementia diagnosis. Incident dated 10/12/2023 resulted in a WIC 5150-72 hour hold for being a danger to others. Prior, to the most recent incident resident (R1) still met admission criteria and behaviors were being managed through program services. As of today, resident (R1) remains hospitalized, and will be re-evaluated prior to discharge in order to determine if resident (R1) still meets admission criteria. There is insufficient evidence to corroborate the allegation.

Allegation: Resident assaulted other residents in care. It is alleged that on 10/12/2023, resident (R1) who resides in the Memory Care "Reflections" unit tried to physically assault resident (R2). In addition, to last week's incident resident (R1) had a previous incident (9/20/2023) in which they became verbally and physically aggressive with resident (R3). Based on interviews conducted, resident (R1) has had several altercations with staff and residents as a result of the resident's medical diagnosis, which includes behavior disturbances exhibited through physical and verbal aggression. Staff stated that the incident dated 10/12/2023 did not result in a physical assault towards resident (R2), but confirmed that during incident (9/20/2023) R1 grabbed R3 and verbally threatened the resident. Staff intervened and separated the residents. No injuries were reported. One (1) out six (6) residents interviewed confirmed the allegation. The residents interviewed did not report safety concerns or knowledge of alleged resident altercations resulting in assaults. Per staff interviews, facility staff immediately respond to incidents. Per record review and observation, there is sufficient staffing in the facility and Reflections unit. The aforementioned incidents, were not a result of lack of supervision or insufficient staffing. Resident (R1's) behaviors are consistent with their medical diagnosis.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Kevin Taliaferro. .A copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
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