198603416-12-10-2021-28-AS-LHIS-C9SN6G-20211217091104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603416
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:59:32 AM

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
12/02/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211202125114

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: 104	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kevin Taliaferro, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is not complying with local public health department's COVID-19 requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint visit to gather information for the allegation of facility is not complying with local public health department’s Coronavirus (COVID-19) requirements. LPA arrived unannounced and met with Executive Director, Kevin Taliaferro. The purpose of the visit was explained.

During the visit today, LPA obtained the staff roster, resident roster, interviewed the Executive Director and the Wellness Director. LPA also interviewed the Pasadena Public Health Department (PPHD) Nurse on a different date.

Regarding allegation, facility is not complying with local public health department’s COVID-19 requirements. It is alleged that the facility failed to submit required documentation on a weekly basis which PPHD sent out to all Pasadena Long Term Care Facilities via email on 9/17/21 informing the standard document submission requirements. (Continue on the LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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-20211202125114

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: 12/10/2021

NARRATIVE

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The Pasadena Public Health Nurse confirmed that the facility failed to submit completed lab reports for twice weekly testing for unvaccinated employees from 9/18/21-11/29/21 and unvaccinated residents from 10/21/21-11/19/21. According to Executive Director (ED) Taliaferro, he acknowledged the test results were not submitted on time weekly for all unvaccinated individuals of the facility for some of the weeks during the months of September to November. He understood the PPHD COVID-19 requirements of testing unvaccinated staff twice a week and unvaccinated residents once per week. He acknowledges the importance of following the guidelines to ensure the health and safety of the residents as well as staff. Per ED Taliaferro, he has delegated a team of staff to prevent this oversight and to ensure the weekly reports for unvaccinated individuals are submitted to PPHD every Monday by 12pm. The Wellness Director also indicated that the required weekly reports for the unvaccinated individuals were not submitted timely to PPHD for about a month, but stated the weekly reports are now being turned in on time.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, LIC9099D, and appeal rights were provided to the Executive Director.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211202125114

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: 12/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/17/2021 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...: (2) Occurrences, such as epidemic outbreaks,... or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate.	1 2 3 4 5 6 7	The Executive Director has delegated staff members to oversee the lab reports for unvaccinated individuals and ensure the lab reports are provided to PPHD weekly. Executive Director will submit a statement adhering to the reporting requirements by POC due date 12/17/21.
	8 9 10 11 12 13 14	Based on interviews, the Executive Director did not ensure that the Pasadena Public Health Department receives their weekly required lab reports for unvaccinated staff and residents which poses a potential health and safety risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC9099 (FAS) - (06/04)

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