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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 08/15/2024
Date Signed: 08/28/2024 01:16:42 PM


Document Has Been Signed on 08/28/2024 01:16 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
MONTEREY PARK ASC, 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:
(626) 204-1700
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:310CENSUS: 141DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Kevin Taliaferro, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Vaid conducted an unannounced Annual Required Visit on 08/15/2024 at 8:50 am. The parking lot and front of facility is clean and free of debris. 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 Vaid requested copies and obtained of Personnel Report and Resident Roster.

Tour of the physical plant was conducted 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 Vaid observed PPE supply station upon entry to the facility.
Kitchen: LPA Vaid 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 Vaid observed staff preparing for dinner. LPA Vaid observed staff wearing gloves and hair netting while preparing and handling food. Kitchen appliances were observed to be clean and in working order. LPA Vaid observed fully charged fire extinguishers in this area. Emergency food supply is stored all throughout the first floor.
Dining Room: Dining room was observed to be clean and contained plenty of seating. LPA Vaid observed three (3) servers taking residents orders and bringing out their meal. Meals are prepared with strict dietary guidelines as ordered by the physicians. Menu is prepared with residents input.
Linen/Laundry/Supply Room: Contained plenty linens, towels, and hygiene products. Toxins and cleaning supplies are inaccessible to residents.

SEE 809-C for continuation.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MORNINGSTAR OF PASADENA
FACILITY NUMBER: 198603416
VISIT DATE: 08/15/2024
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Resident Rooms: LPA Vaid observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Vaid selected ten(10) resident rooms at random to inspect.
Bathrooms: LPA Vaid tested water temperature in ten (10) 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 the toilet.
Centrally Stored Medications: LPA Vaid observed several medications carts to be locked during visit. LPA Vaid observed med carts on each floor and medications being dispensed to residents.
Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors LPA Vaid observed posted Emergency Disaster Plan and evacuation maps posted at every corner. Fire extinguishers are located throughout the facility and were observed to be fully charged.
Emergency Drills: Drills are conducted by third party vendor, drills are conducted monthly with role-play scenarios, like fire in waste basket, fire in hallway, earthquake evacuations.
Staff Personnel Files: Ten (10) staff files were reviewed, and nine (9) staff were interviewed. LPA Vaid did not find any discrepancies in personnel files. Administrator license expires 09/03/2024, renewal is pending process.
Resident Files: Eight (8) resident files were reviewed, and ten (10) residents were interviewed. LPA Vaid did not find any discrepancies in resident files.
Liability Insurance & Infection Control Plan: LPA Vaid obtained a copy of facility Infection Control Plan and current liability insurance with an expiration date of 9/29/24.

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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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