<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603416
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:18:32 PM

Document Has Been Signed on 01/19/2022 12:18 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
CCLD Regional Office, 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: 106DATE:
01/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Executive Director Kevin Taliaferro,
Wellness Director Rhonda Guzman		TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced case management visit to this facility. During the initial 10-day complaint visit conducted on 1/19/22, the following concern was observed upon entering the facility;

Upon arriving at the facility at 9AM, LPA was greeted by Staff #1 (S1) and LPA 9 was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to Executive Director Kevin Taliaferro, along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/19/2022 12:18 PM - It Cannot Be Edited


Created By: Nune Margaryan On 01/19/2022 at 11:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2022
Section Cited
HSC
1569.50(a)(3)

1
2
3
4
5
6
7
a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
1
2
3
4
5
6
7
Executive Director will ensure that all facility staff are following California Dept of Public Health and CCLD requirements by conducting an in-service training with the staff on the importance of COVID screening for all visitors, staff and residents. Executive Director will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Upon arriving at the facility at 10:30 am LPA was greeted by Staff #1 (S1) and LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2