198603416-11-13-2023-28-AS-MVAO-CYWSHZ-20231227125423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 11/13/2023
Date Signed: 11/13/2023 11:09:23 AM

Substantiated

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
05/03/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20230503110725

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:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Executive Director Kevin Taliaferro		TIME COMPLETED:	11:24 AM

ALLEGATION(S):

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Facility left resident unsupervised in facility vehicle.
Facility did not provide care to resident.

INVESTIGATION FINDINGS:

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On 11/13/2023 at 9:05 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent 10- day complaint visit to investigate the allegations listed above. LPA met with Executive Director Kevin Taliaferro and explained the reason for the visit.

During the initial visit on 5/11/2023, LPA toured the facility and conducted a file review for R1. LPA obtained the resident roster, staff roster, R1's admissions agreement, needs and services plan, physicians report, assisted living services, pre-trip shuttle inspection sheet, Van self- Inspection Report, and facility transportation safety team member guide. LPA also interviewed: the Executive Director and a total of three (3) staff who shall be referred to as S2 through S4. LPA contacted and interviewed former staff (S1) and attempted to contact staff (S5). LPA interviewed a total of 10 residents who shall be referred to as R2 through R11.

Report Coninued on 9099c

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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-20230503110725

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: 11/13/2023

NARRATIVE

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During today’s visit LPA interviewed R1’s family member (FM) and delivered findings.

The investigation reveals the following: Regarding “Facility left resident unsupervised in facility vehicle”. It is alleged that the facility left R1 on the facility shuttle from 3 pm- 8:45 pm. The Executive Director confirmed there was an incident where S1 forgot R1 in the vehicle. Shas since been dismissed from their position. 3 out of 3 staff confirmed that S1 left R1 in the vehicle unintentionally, and R1 was sent to the hospital for further evaluation. 7 out of 10 residents stated they use the facility shuttle and have had no issues. 3 out of 10 residents stated they do not use the facility shuttle. Upon file review, LPA observed R1 has a secondary diagnosis of Dementia. LPA also received an incident report from the facility confirming the incident.

The investigation reveals the following: Regarding “Facility did not provide care to resident. It is alleged that the facility did not provide care for the resident during the hours the resident was left unattended in the facility shuttle. The Executive Director confirmed there was an incident where S1 forgot R1 in the vehicle. 3 out of 3 staff confirmed that S1 left R1 in the vehicle unintentionally. 8 out of 10 residents confirmed the facility provides care. 2 out of 10 residents stated the facility do not provide enough care. LPA Baptiste received an incident report from the facility confirming staff tried to locate R1 but did not find R1 until 8:45 pm. During the time the resident was in the shuttle, no care was provided.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D and civil penalties assessed.

Exit Interview Conducted with Executive Director Kevin Taliaferro/ Appeal Rights Provided / Civil Penalties Assessed/ A Copy of the Reports Issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 28-AS-20230503110725

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/14/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director will submit in writing what steps they will take to ensure that residents are not left unsupervised at any time. The Executive Director will also provide staff training regarding the process of a missing resident. The Plan of correction will need to be submitted to licensing by POC date. Executive Director requested Thursday 11/16/2023 to complete inservice training.
	8 9 10 11 12 13 14	Based on observation, interviews conducted and file review, it was revealed that R1 was left unattended in the facility van from 3:00 pm to 8:45 pm, which poses an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14	** Civil Penalties Assessed on LIC421M**
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	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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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