Morningstar of Pasadena

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit and met with the Wellness Director, Rhonda Guzman and LPA explained the purpose of the visit. The Facility is licensed to serve 310 non- ambulatory adults 60 and over, of which 25 may be bedridden. Facility has an approved hospice waiver for 30 residents. On today's date, LPA utilized the Compliance and Regulatory Enforcement (CARE) tools and inspected the three (3) domains including: Resident Rights/Information, Planned Activities, and Food Services. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the mailing area. The facility provides internet service to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Facility has a Life Enrichment Director, who coordinates activities provided at the facility. LPA observed various areas throughout the facility that provides puzzles, games reading areas, gardening. Memory Care Unit has an activity area that promotes painting with a system for other sensory activities. Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Currently, there are two (2) residents with modified diets. Sanitation practices and kitchen cleanliness was observed. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report was provided to the Wellness Director, Rhonda Guzman.the state’s words, verbatim · CDSS document, Aug 7, 2026

Allegation investigated: Staff manipulates residents.

Liciencing Program Analyst (LPA), Mayra Cota, conducted an initial 10-day investigation visit regardin the above mentioned allegation. LPA, met with Kevin Taliaferro, Executive Director, and the purpose of the visit was explained. The investigation consisted of the following: during today's visit, LPA conducted tour of the facility, obtained staff and resident rosters, and interviewed Staff 1 - Staff 11 (S1-S11) and Resident 1 - Resident 11 (R1-R11). The investigation consisted of the following: Regarding: Staff manipulates residents. It is alleged that staff manipulates residents and instills fear to get what they want. It is also alleged that a resident wanted a status on recent stock investments from a facility staff. ***Continues on 9099-C*** Unsubstantiated Interviews with (11) out of (11) staff deny the allegation. Staff interviews revealed that they do not manipulate nor instill fear in residents to obtain what they want. Staff indicated that they do not manipulate residents into giving them material things because it is abuse and it is against the facility’s policy to engage in that kind of behavior. Staff also stated that they have not heard concerns from residents that staff are instilling fear to get things from them. Furthermore, staff indicated that residents have not expressed concerns about being manipulated into giving staff what they want. Staff also indicated that staff do not provide residents with financial advice nor offer residents investment stocks for purchase. Staff also do not give updates on stock investments or any other financial information to residents. Interview with S1 revealed that they do not manipulate residents nor instill fear to obtain things S1 wants. S1 indicated that they have never received anything from residents, not even a tip because policy does not allow it and it is something that S1 simply would not do. S1 indicated that anything infringing on residents’ rights and anything indicative of financial abuse would be reported immediately to the appropriate authorities. S1 further indicated, S1 has never received property nor vehicles from residents nor has it been reported to S1 that staff have received these types of items from residents. Eleven (11) out (11) staff indicated, they are mandated reporters and would report abuse of any type, even financial abuse to licensing, ombudsman and law enforcement if pertinent. Interviews with (11) out of (11) residents also deny the allegation. Resident interviews revealed that staff do not manipulate nor instill fear in residents to obtain any monetary or material compensation. Resident interviews also revealed that staff do not discuss nor offer investments stocks to residents. Residents further indicated that they have never furnished S1 with monetary compensation nor material items. Residents stated that S1 has never manipulated nor intimidated them into giving S1 property or vehicles. Residents indicated that all the staff are professional and do not instill fear to get things from residents. Residents further indicated that they have no concerns with how S1 and the rest of the staff conduct themselves in the facility and stated that their needs are being met appropriately. Interview with R1 indicated that they do not own any stocks (not even for the facility’s corporation), has never been offered to buy any stocks, nor has ever been manipulated or intimidated by S1 nor other staff to provide them with money or other material goods. R1 stated, “Staff have never discussed financial things with me. I have never been bribed or intimidated into giving staff money or other material processions. Staff here are very professional. I have no concerns.” Based on information gathered during interviews with staff and residents, the allegation could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Kevin Taliaferro, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 28-AS-20251022101920

Allegation investigated: Staff are not ensuring that proper infection control practices are being followed.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint investigation visit regarding the above-mentioned allegation. Today’s visit stems from an initial complaint investigation which took place on 9/4/25. LPA met with Kevin Taliaferro, Executive Director, and explained the reason for the visit. The investigation consisted of the following: LPA, obtained copies of staff and resident rosters, toured the facility, interviewed Staff 1 – Staff 7 (S1-S7), Resident 1 – Resident 7 (R1-R7) and Service Representative from Public Health Department. Also, during today’s visit, LPA reviewed facility’s Infection Control Plan, Facility’s Daily COVID-19 Report (8/19/25-9/10/25) and COVID-19 Protocol and Preparedness and Response Plan. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff are not ensuring that proper infection control practices are being followed. It is alleged that the facility had five cases of COVID and that the facility has communal dining, not requiring facial coverings and not taking the proper precautions. Interviews with (7) out of (7) staff deny the allegation. Staff interviews indicated that the facility follows all protocols in place to mitigate a COVID outbreak. Staff stated, as soon as symptoms were reported by residents or staff, testing was conducted on site. Residents who tested positive were placed on isolation; however, med-tech and caregiving staff continued to conduct wellness checks on all residents as normally as possible. Positive cases were reported to administrative staff, physicians, family and to the local public health department. Staff received refresher training on the proper use of PPE and safe sanitation practices, and staff who had direct contact with residents with COVID wore the proper PPE and disposed of it accordingly after use. Staff further indicated, face masks were mandatory for all staff and made available for residents, via carts placed in the facility’s hallways which were stocked with sanitizing wipes, disinfectant spray, masks and gloves. Testing was conducted daily during the peak of the outbreak for all residents and staff and all activities and communal dining were suspended temporarily. Meals were provided to all residents in their room using disposable cutlery and dishes. Common areas and resident rooms were cleaned and disinfected constantly. Interviews with (7) residents indicated that facility staff took the proper precautions to prevent the spread of infection. Residents stated that the facility was constantly being cleaned and sanitized and that all staff were observed wearing masks. Residents stated that they were tested throughout the outbreak and that meals were delivered to their rooms and all activities and eating in the dining area were canceled temporarily. Interview with Public Health Service Representative indicated that the facility followed infection control procedures as best as possible and testing and positive cases were reported accordingly. Service Representative further indicated Public Health Department was informed about the practices conducted at the facility to help prevent infection, which were taking place during the spike and further stated they have no concerns regarding the facility not being responsive during their outbreak. Review of the facility’s Infection Control Plan and COVID Protocol and Preparedness Plan indicates that the facility is following measures to prevent infection. LPA toured the facility and did not observe any infectious materials or fluids not properly managed. Based on interviews, record review and observations, the allegation could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Kevin Taliaferro, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250828110401

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced Case Management -Annual Continuation visit at the facility to continue annual visit initiated on 9/19/25 using the CARE tools. LPA met with Kevin Taliafero and explained the reason for the visit. The following domains were completed during this visit: Personnel Records/Staff Training: LPA reviewed 10 staff files. Files were available for review, Files include; TB clearance, health screening, background clearance, personnel record, and training. Five staff were interviewed. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in medication room and in the dementia unit. LPA reviewed medication for 10 residents. A log for PRN/Narcotics medication was observed. Resident #6(R6) had clotrimazole 1% cream out of original container without pharmacy label. Resident Records/Incident Reports: LPA reviewed 10 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal. Appraisal for R4 was last done on 6/26/23, Resident #5(R5) was last done on 4/16/24, R6 was last done in 8/14/23, Resident #9(R9) pre-appraisal was done in 3/3/19. Five residents were interviewed. Residents with Special Health Needs Facility: Facility is serving 5 residents on hospice. Two hospices plans were reviewed. Facility does not have bodies of water. Dementia unit residents do not have access to knives/sharps, chemicals or medications. A delay egress system was observed and tested in the dementia unit. Deficiencies noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Kevin Taliaferro and explained the reason for the visit. Facility is licensed to serve 310 non- ambulatory adults 60 and over, of which 25 may be bedridden. Facility has an approved hospice waiver for 30 residents. Facility consist of a lobby, dining room, bristo bar, library, commercial kitchen, medication office, a therapy room, garden area, several lounge rooms, game/puzzle room, activity rooms, a theater, and other common areas through the 4th floors. It consist of 4 floors each floor has assisted living, the 2nd floor has a dementia unit with outdoor patios and common areas. LPA toured the facility with Kevin Taliaferro, the following domains were reviewed during this visit: Infection Control: Facility maintains a copy of infection control. Housekeeping staff were observed maintaining sanitizing procedures. Staff files were not reviewed today. Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. A current liability insurance was observed. Physical Plant/Environmental Safety: During facility's tour LPA observed all common areas in good repair. A total of 13 random assisted living residents' rooms and 2 resident rooms in the dementia unit. Each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 105.0-118.5 degrees F., which is within the required 105-120 degrees F. Bathrooms were observed with grab bars and slip flooring in the showers. Medication is stored in medication carts locked and inaccessible to residents. Passageways, hallways, stairways are clear of debris and obstructions. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 5/9/25. Delay egress exit doors were observed in working condition. Elevators were observed in working. There are no large bodies of water. (CONTINUED ON LIC 809C) Staffing: Administrator certificate was reviewed for Kevin Taliaferro #7023019740 exp. date: 9/32026. CPR/First aid training was observed for staff. Three employees are on duty on the assisted living area and 2 in the dementia unit on the premises during the night shift. Resident Rights/Information: License, Ombudsman, personal rights posters were posted in the mailing area. Let us Know (PUB 475) was not observed. Planned Activities: Facility has a Life Enrichment Director, who coordinates activities provided at the facility. LPA observed various areas throughout the facility that provides puzzles, games reading areas, gardening. Memory Care Unit has an activity area that promotes painting with a system for other sensory activities. Food Services: LPA toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed. Disaster Preparedness: LPAs reviewed facility's emergency disaster plan, no yearly review log was observed. Evacuation chairs were observed in each staircase. Emergency disaster drills are conducted quarterly, last was conducted on 7/23/25. Staff and resident files, medication, and interviews with staff/residents were not conducted during this visit. Due to time LPA will return at a later time to finish the visit. No deficiencies were noted during this visit a Technical Violation was noted during this visit. Exit interview was conducted with Kevin Taliafero and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained a severe pressure injury due to staff neglect Staff are not properly trained

**This is an amended report of original report dated 04/15/25, the purpose for amendment is to remove confidential information. This amended report does not change the findings. LPA Margaryan redelivered report and obtained signature on 04/29/25.** Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to deliver findings for the allegations listed above. LPA met with Kevin Taliaferro, Executive Directorand explained the reason for the visit. Investigation consist of following: At the time of Department’s visits conducted on 08/17/23, 01/11/24,01/23/24 and 03/28/25 copies of residents and staff roster requested, Resident #1(R1’s) file was reviewed and the following was obtained: Identification and Emergency Information Sheet, Admission Agreement, Agreements and Consent for Medical Treatment, Physician's Report, PRN Authorization Letter, Agreements and Consent for Medical Treatment, Medication List, Clinical Notes, Care Plan, Hospice Documents, R1’s Annual Evaluation,R1’s Death Certificate, Staff training materials: Certificates of proper Positioning, Copies of Care Tracking Sheets. Interviews were conducted with facility staff and Family Members (FMs). At the time of visits was not observed any immediate health and/or safety concerns. Continue 9099C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained a severe pressure injury due to staff neglect. It was alleged that resident developed the bed sore due to due to staff neglect, not being rotated. Per hospice and facility records obtained by the Department, it was discovered that R1 was admitted to the facility under hospice care services due to R1’s health condition. Prior to R1’s admission to the facility, she was at SNF. According to Family Member 1 (FM1) When R1 arrived at Morningstar of Pasadena facility R1 had “complexity of health issues” which resulted R1 to become bedbound. FM1 indicated per S3, R1 developed the pressure injury due to not being rotated. Interviewed Family Member 2(FM2) indicated that they were not aware of R1’s health conditions and stated that R1 kept it confidential between themselves and their doctor. Interviewed S1 and S2 indicated that during R1’s admission, she had a presented pressure injury on her coccyx which would open and close through the course of being alive at the facility. For a while R1 was ambulatory, but overtime while R1 was living in the facility, R1’s health was declining. Interviewed staff stated R1 was provided care by a hospice nurse and the facility’s staff. Interviewed S1 and S2 denied the allegation. They stated that facility staff did not neglect R1’s which resulted in a pressure wound deteriorated. They stated that R1 had a psychological and eating issues. S1 and S2 stated that Facility staff encouraged R1 to dine with their family members, to increase R1’s mobility but R1 became uncomfortable and depressed. Facility staff ended up feeding R1 in their room when R1 completely became bedbound. Interviewed staff stated that every two to three hours staff were responsible for rotating and repositioning R1 as instructed by hospice. Interviewed S3 stated that caregivers not allowed to provide wound care. Only LVNs and Hospice nurses. S3 stated that R1’s wound progressed while R1 was at the facility, but not able to provide any details or verify if the pressure injury was evaluated. S3 indicated that facility staff and caregivers were given instructions by Hospice staff and facility LVNs to rotate and reposition R1 every 2 hours. Interviewed Staff indicated that Hospice nurses came to the facility twice a week and provided comfort care and wound care to R1. Hospice document review revealed that hospice staff observed R1 was well cared, and hospice staff did not have concerns during visit. Due to the R1’s health condition, it was hard to prevent R1 from to sustaining pressure wounds, regardless of how well the wounds were being cared for and how often R1 was being repositioned/ rotated. Per hospice staff notes / reports, facility staff were provided good care to R1 and followed all instructions from Hospice. R1 passed away at the facility on 07/22/23 while a hospice care nurse and Family members were by R1’s side. Death certificate notes R1 passed away due to Atherosclerotic Cardiovascular disease. Therefore, this allegation is unsubstantiated. Continue 9099C Allegation: Staff are not properly trained. It was alleged that Facility staff not trained how to rotate the residents and haven’t been instructed on what to do. Per hospice and facility records obtained by the Département, it was discovered that R1 was admitted to the facility under hospice care services due to R1’s health condition. Review of documentation obtained from Hospice and facility revealed that R1 was being treated for pressure injuries. Documentation also shows that facility staff were given the instruction to rotate the resident every two hours to relieve pressure. During the interviews with staff, department was advised that the facility caregivers followed the instructions from the Hospice care and the residents care plan. Interviewed staff stated that every 2-3 hours staff were responsible for rotating and repositioning R1 as instructed by Hospice. Rotations were documented using the PCC (old) and Alis (new) program. In service training on Rotating Residents every 2 hours was provided to facility staff. Department obtained and reviewed the training materials for residents rotation and staff Certificates of Completion for Proper Positioning, Care tracking sheets. Facility staff also demonstrated how is working the program and was observed that staff documented / signed all services and cares provided to resident, including repositioning in the system. All caregivers were able to log in the care system using their cellphones. Based on the record reviews, observations and interviews conducted with staff there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and the copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 28-AS-20230816165341

Allegation investigated: Staff neglect resulted in a resident sustaining a death. Staff mishandled the residents medications.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced subsequent complaint investigation regarding the above allegations. LPA met with Kevin Taliaferro, Executive Director and discussed the purpose of the visit. The investigation consisted of the following: LPA requested copies of Residents & Staff Roster and conducted a tour of facility. LPA reviewed and received copies from Resident #1's (R1) file and Death report. During today’s visit LPA interviewed Executive Director, Wellness Director, Staff #1 – Staff #4 (S1 – S4), Residents #2 – Residents#11 (R2 – R11). S4 and Resident #1’s (R1) family member (FM) were interviewed over the phone. Continue 9099C Unsubstantiated Regarding allegation: Staff neglect resulted in a resident sustaining a death. It was alleged that there was one occasion where a resident had passed away in his room and no one knew or found him until 3 days later when resident’s son called for a welfare check. Interviewed Executive Director, Wellness Director and (4) of (4) staff denied the allegation. (10) of (10) residents interviewed could not corroborate the allegation. Interviewed FM stated that they spoke with R1 every day. FM stated that R1 never expressed dissatisfaction about facility. R1 always said that he/she felt very comfortable at the facility and facility staff very attentive and caring towards him and other residents. Facility staff always kept FM informed about R1. FM stated that Facility staff were very caring and R1 died a natural death, and FM has no concerns about that. Staff informed FM of the death on the same day R1 died and staff did everything right. Executive Director stated that he was at the facility on 06/08/24 from 5:00 am and stayed to about 9:00 am. Executive Director saw R1 at the Bistro around 8:00 am having breakfast. They chatted briefly, which was normal for them. Later that evening R1 had passed and by the protocol, staff called 911 and family members were notified. Wellness Director stated that facility staff monitor all resident's closely to assess and determine if there is an immediate concern that requires immediate attention. There has never been a case where a resident passed away in his room and staff were not aware of it. Interviewed S1, S2, S3, S4 stated that staff frequently check on residents and there was no incident that resident passed away at the facility and staff didn’t know about that until 3 days. Continue 9099C Staff mishandled the residents medications. It was alleged that residents are complaining that they received wrong medication and Wellness nurse take residents medication and take home. Interviewed Executive Director, Wellness Director and (4) of (4) staff denied the allegation. They stated that staff administrated medications by physician's order and in a timely manner and no one take resident’s medications home. They stated that the medications are kept locked at all times. (10) of (10) residents interviewed could not corroborate the allegation. Interviewed Executive director and Wellness Director stated that they didn’t hear any complaints about residents received wrong medication or staff takes residents medications home. Interviewed S4 stated they never took residents medication home. S1, S2, S3 and S4 stated that all medications are administrated as prescribed and are noted electronically through an "Alis" program and all residents’ medications are registered under the "Alis" program. Interviewed staff demonstrated to LPA how is worked "Alis" program. LPA observed that residents medications are registered under the "Alis" program. LPA didn’t find any discrepancy. LPA toured the medication room and confirmed medications are kept locked. Interviewed staff stated if there are discontinued medications or medications for the residents who moved / passed away from the facility and didn't take medications with them, will be destroyed in a proper way. Medications are destroyed by assigned staff and facility keeps record of destroyed medications (documents were provided). Residents interviewed stated that staff administrated medication correctly and they don't have any concerns regarding their medications. The information gathered does not corroborate the allegation noted above. Based on the file/record reviews, observations and interviews conducted with staff and client there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and the copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 28-AS-20240811211753

Allegation investigated: Unqualified staff are administering injections to residents. Unqualified staff are taking residents vital signs.

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegations listed above to deliver finding to the complaint allegations. On 12/17/2024, the investigation consisted of the following: LPA obtained copies of Staff & Client Rosters, Official Transcripts and Course Completion History (7) Med Techs, copy of Staff by department, name list of resident care of level. Name list of residents who are prescribed injections. Collected face sheet, physicians report, eMARs list, and residents' Needs/Services and care plans, four (4) residents. Staff file for LVN nurses. LPA interviewed 6 staff and 4 residents. On today’s date 01/30/2025 visit LPA Vaid interviewed 5 residents. Regarding the allegation: Unqualified staff are administering injections to residents. It is alleged that management staff is making the med-techs administer injections to residents when the med-tech are clearly not trained on how to administer injection. Continued on 9099C....... Unsubstantiated Six (6) out of six (6) staff interviewed deny this allegation. Nine (9) out of nine (9) residents interviewed could not corroborate this allegation. The facility is an assisted living facility, not a medical facility. The residents R1-R4, who receive injections for their health condition say they are assisted by the med-techs when administering self-injection of the medication. The med-techs prepare and hands the inject to the resident to self-inject. A times when residents are feeling weak or are unsure of the injection protocols due to forgetfulness or other issues. The med-tech will use hand-over-hand method of delivering the medication to the resident. The resident is in full control of the syringe as it penetrates the skin and medication is then injected into the body. LPA observed med-tech prepare the injection syringe by turning the insulin pen to fill dosage into the vial, then discuss with resident of the medication to be injected. The med-tech then hands the insulin pen for the resident to self-inject. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations is unsubstantiated. Regarding the allegation: Unqualified staff are taking residents vital signs. It is alleged that unqualified staff are taking vital signs of the residents when the staff are not trained to do so. Six (6) out of six (6) staff deny the allegation. Nine (9) out of nine (9) residents could not corroborate this allegation. Vital signs are taken for residents who show trends of abnormal readings via electronic medical recording device by the licensed medical professional. LVN’s are on call and reached when readings shown on electronic instrument reading is systolic below 90 and diastolic is less than 60. When residents pressure reading is abnormal from the reading of the medical device the LVN will then conduct a manual check of the residents’ pressures, the LVN will then notify the residents physician and communicate the readings. The doctor will give instruction to LVN on procedures regarding resident’s health and level of care to be provided. The protocols for checking the vitals for the residents, check the physician orders if vitals are needed recording (not all residents are having physician orders for vitals checked daily). Med-techs dispense medication to same residents for one week at a time becoming familiarized with residents’ medications, and any visible changes to resident health to report back to the LVN for further assistance. Licensed Vocation Nurses using the electronic medical device for vitals, records and forwards to residents’ physician monitoring their patients daily/weekly vital trends due to changes in medication or other medical issues determined by the doctor. Only licensed medical professionals are recording the medical device readings and reporting information to the residents’ physicians. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegation is unsubstantiated. Exit interview conducted with Kevin Taliaferro, administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 28-AS-20241216131145

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Aug 15, 2024

Type of visit: Office

An Informal Conference meeting was held at the Monterey Park Adult and Senior Care Regional Office. Present during this meeting were Licensing Program Manager (LPM) Fernando Fierros, Licensing Program Analyst (LPA) Sanjay Vaid, and from Morning Star were Administrator Kevin Taliaferro, and Authorized Representatives Steve Martin, Chad James and Melissa Clement.. The following items listed below were discussed during today's meeting: Complaint investigation findings for complaint # 28-AS-20230503110725 Section 87468.2 - Facility did not have sufficient staff to meet residents needs Section 87468.2 Facility is not providing reasonable accommodations to residents in care Section 87415 - Night supervision- Emergency personnel could not access facility Section 87303 - Facility in Disrepair Section 87211- Facility did not report COVID-19 outbreak to the department per Title 22 Regulations. The following Title 22 topics were discussed and a copy of the Section given during office meeting: Night Supervision, Section 87415 Additional Personal Rights of Residents in Privately Operated Facilities, Section 87468.2 Infection Control Requirements, Section 87470 Reporting Requirements, Section 87211 Maintenance and Operations, Section 87303 Annual Licensing Fees in the amount of $3300.00 are due by 09/23/2024. Fees will paid prior to the due dates. A copy of the licensing fees were provided during office meeting. Administrator Taliaferro, stated the plan of corrections that were implemented to ensure the safety of the facility and of the residents. A plan to utilize the parking lot for construction purposes will be provided to the department. An exit interview was conducted and a copy of the report was provided to the Administrator Kevin Taliaferro.the state’s words, verbatim · CDSS document, Jul 26, 2024

Allegation investigated: Staff mismanaged a resident's medication record.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Executive Director Kevin Taliaferro and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff & Client Rosters, Official Transcripts and Course Completion History for Med Techs, copy of Med Staff Schedule. LPA also interviewed Staff #1 - Staff #5 (S #1-S #5). S# 4 was interviewed over the phone. Medication Administration Records (electronic MAR and paper MAR) were reviewed. Continue 9099C Unsubstantiated The investigation revealed the following: in regard to the allegation " Staff mismanaged a resident's medication record", it is alleged that someone signed initials for med tech that wasn't there, and director of the department is not doing anything about it. Staff interviewed deny the allegation. Records reviewed did not support the allegation. There were no errors observed during the Medication Administration Records review. LPA didn't find any discrepancy and could not locate any documents that suggest facility staff sign initials for another med tech who wasn't there. Staff interviewed deny the allegation. They stated that everyone has their own passwords to log in in the system / MAR, and they can’t sign for another Med Tech, and someone can't sing for them. There were no witnesses to this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was provided to Executive Director Kevin Taliaferro.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 28-AS-20240220084940

Allegation investigated: Facility is not complying with Covid-19 regulations by requiring staff to return to work 3-5 days after testing positive for Covid. Administrator is opening dining room to residents even though facility has a Covid outbreak.

Licensing Program Analyst (LPA)s Sanjay Vaid and Mary Flores conducted a subsequent complaint visit regarding the allegation stated above. LPA's met with Administrator Kevin Taliaferro and explained the reason for the visit. The investigation consisted of the following: On 01/19/2022 visit LPA Margaryan toured the facility dining room, Interviewed Executive Director Kevin Taliaferro, collected copies of residents and staff roster, the licensees requirements / clearance forms regarding returning to work who have tested Covid 19, Health order from Pasadena Public Health Department (PPHD). On 01/30/2024, LPAs obtained copies of staff and resident rosters, reviewed daily COVID 19 logs from 12/01/2021 thru 01/31/2022, interviewed Administrator, Staff 1-7 (S1-S7), Resident 1- 10 (R1-R10). (Continued to LIC 9099-C) Unsubstantiated Investigation revealed the following: regarding allegations, Facility is not complying with Covid-19 regulations by requiring staff to return to work 3-5 days after testing positive for Covid. It is alleged that Administrator Kevin want the staff back within 3 days after testing positive for COVID 19. Interviews with ten (10) residents revealed the facility follows and will follow protocols in place regarding COVID 19. Interviews with seven(7) staff reveals that during COVID 19 onset the staff will quarantine for 5 days on the sixth day will return to work if tests results shown are negative COVID 19, if test result are positive then staff will continue to quarantine for 10 days. As per Administrator and Wellness Director all staff whom tested positive needed to present letter of clearance before returning to work. Daily logs reviewed for dates December 2021 to January 2022 all staff whom tested positive were reported to Pasadena Public Health. Per Pasadena Public Health. Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegation: Administrator is opening dining room to residents even though facility has a Covid outbreak. It is alleged that Administrator Kevin wants to open the dinning room during COVID 19 outbreak. Interviews with ten (10) residents revealed six (6) residents stated that the dining rooms was closed during COVID 19 outbreaks and that meals were served in their rooms, 4(four) residents are unsure of the protocols but feel comfortable the dining room will be closed if an outbreak were to occur. Interviews with seven (7) staff reveals the during outbreak protocols were put into action. Two residents per table were allowed, social distancing rules were applied, residents whom were ill received meals in their rooms. Per Pasadena Public Health guidelines, it was recommended that tables be sanitized after each use, clean and sanitize common areas frequently. Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview held and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 28-AS-20220112132407

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

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 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.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20230503110725

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 14, 2023

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: 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.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: 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. **** Civil Penalties Assessed on LIC421M****

Allegation investigated: Staff are not able to adequately care for resident due to resident needing higher level of care. Resident assaulted other residents in care.

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 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.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231016185047