Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. However, some complaint investigations substantiated issues related to insufficient staffing, failure to provide reasonable accommodations, facility disrepair including flooding and plumbing problems, and delays in incident reporting. The most serious event occurred in November 2023 when a resident was left unattended in a facility vehicle for several hours, resulting in staff dismissal and civil penalties. The most recent report from October 3, 2025, noted minor deficiencies involving medication storage and resident reappraisals but no severe issues. Overall, the facility’s record shows improvement in recent annual inspections, with the latest annual visit in September 2025 finding no deficiencies.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 2
Oct 3, 2025
Visit Reason
An unannounced Case Management - Annual Continuation visit was conducted to continue the annual inspection initiated on 2025-09-19 using CARE tools.
Findings
The inspection reviewed personnel records, staff training, medication storage and administration, resident records, and special health needs. Deficiencies were noted related to medication storage and timely resident reappraisals.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #6 had a prescribed medication (clotrimazole 1% cream) out of its original container without a pharmacy label. | Type B |
| Four out of ten residents did not have a pre-admission appraisal updated within the last 12 months. | Type B |
Report Facts
Staff files reviewed: 10
Residents' medication reviewed: 10
Residents' files reviewed: 10
Residents on hospice: 5
Residents interviewed: 5
Residents with outdated appraisals: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during inspection and named in medication deficiency finding |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and signed the report |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 0
Sep 19, 2025
Visit Reason
An unannounced annual inspection visit was conducted using the CARE tool to evaluate compliance with licensing requirements and facility operations.
Findings
No deficiencies were noted during this visit; however, a technical violation was observed. The facility was found to be in good repair, operating within license limitations, and maintaining proper infection control, safety, and operational standards.
Report Facts
Licensed capacity: 310
Current census: 151
Fire extinguisher last checked: May 9, 2025
Emergency drill last conducted: Jul 23, 2025
Administrator certificate expiration: Sep 3, 2026
Number of employees on night shift: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection; certificate reviewed |
| Mary G Flores | Licensing Evaluator | Conducted the unannounced annual visit and inspection |
| Wei Siew Ho | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Apr 15, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a resident sustained a severe pressure injury due to staff neglect and that staff were not properly trained.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Records and interviews indicated that the resident was under hospice care, staff followed instructions for repositioning every 2-3 hours, and training was provided. The resident's pressure injury was present upon admission and worsened due to health conditions. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that a resident sustained a severe pressure injury due to staff neglect and that staff were not properly trained. The investigation included review of resident and staff records, interviews with staff and family members, and observation of care practices. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 310
Resident census: 148
Visit start time: 900
Visit end time: 1010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during inspection and named in report |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Mar 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations of staff neglect resulting in a resident's death and staff mishandling residents' medications.
Findings
The investigation found no corroborative evidence to support the allegations. Interviews with staff, residents, and family members, as well as record reviews, indicated that the resident died a natural death and medications were administered properly and securely. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff neglect resulted in a resident sustaining a death and that staff mishandled residents' medications by giving wrong medications and taking medications home. The investigation included interviews with the Executive Director, Wellness Director, staff, residents, and a family member, as well as review of records and observation of medication administration processes. The allegations were found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 310
Census: 146
Number of allegations: 2
Number of staff interviewed: 4
Number of residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed regarding allegations and during exit interview |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 310
Deficiencies: 0
Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that unqualified staff were administering injections and taking residents' vital signs.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and observations showed that med-techs assisted residents with self-injections without administering injections themselves, and only licensed medical professionals recorded and reported vital signs.
Complaint Details
The complaint alleged that unqualified staff were administering injections and taking vital signs. The allegations were unsubstantiated after interviews with staff and residents and review of protocols and observations.
Report Facts
Staff interviewed: 6
Residents interviewed: 9
Staff interviewed: 6
Residents interviewed: 9
Med techs reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and exit interview |
| Sanjay Vaid | Licensing Program Analyst | Conducted complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 141
Capacity: 310
Deficiencies: 0
Aug 15, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were cited during the inspection. Staff personnel and resident files were reviewed without discrepancies. Safety equipment and emergency plans were in place and functional.
Report Facts
Licensed capacity: 310
Current census: 141
Bedridden residents allowed: 25
Hospice waiver residents allowed: 30
Staff files reviewed: 10
Staff interviewed: 9
Resident files reviewed: 8
Residents interviewed: 10
Water temperature range: 105
Water temperature range: 120
Infection control plan expiration: Sep 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sanjay Vaid | Licensing Evaluator | Conducted the inspection and authored the report |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 5
Jul 26, 2024
Visit Reason
The visit was conducted as a complaint investigation related to complaint #28-AS-20230503110725, addressing issues such as insufficient staffing, lack of reasonable accommodations, night supervision problems, facility disrepair, and failure to report a COVID-19 outbreak.
Findings
The investigation found multiple deficiencies including insufficient staff to meet residents' needs, failure to provide reasonable accommodations, emergency personnel access issues during night supervision, facility disrepair, and failure to report a COVID-19 outbreak as required by Title 22 regulations.
Complaint Details
Complaint investigation findings for complaint #28-AS-20230503110725 were discussed, confirming multiple regulatory violations.
Deficiencies (5)
| Description |
|---|
| Facility did not have sufficient staff to meet residents needs |
| Facility is not providing reasonable accommodations to residents in care |
| Night supervision - Emergency personnel could not access facility |
| Facility in disrepair |
| Facility did not report COVID-19 outbreak to the department per Title 22 Regulations |
Report Facts
Annual Licensing Fees: 3300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to plan of corrections and exit interview |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Feb 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff mismanaged a resident's medication record.
Findings
The investigation found no evidence to support the allegation. Staff denied the claim, records reviewed showed no errors, and no discrepancies were found in the Medication Administration Records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The allegation was that someone signed initials for a med tech who was not present and that the department director was not addressing the issue. Staff interviews and record reviews did not support this claim, and no witnesses were found. The allegation was unsubstantiated.
Report Facts
Capacity: 310
Census: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Jan 30, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that the facility was not complying with Covid-19 regulations by requiring staff to return to work 3-5 days after testing positive and that the administrator was opening the dining room during a Covid outbreak.
Findings
The investigation found that staff followed quarantine protocols requiring 5 days quarantine and negative test results before returning to work, with clearance letters required. Dining room protocols during outbreaks included limited seating, social distancing, and sanitization. There was insufficient evidence to prove the allegations, so they were unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and staff, review of logs, and public health guidelines. There was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 310
Census: 146
Staff interviewed: 7
Residents interviewed: 10
Daily COVID-19 logs reviewed: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to allegations and interviews regarding Covid-19 protocols |
| Sanjay Vaid | Licensing Program Analyst | Conducted complaint investigation |
| Mary Flores | Licensing Program Analyst | Conducted complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 1
Nov 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility left a resident unsupervised in a facility vehicle and did not provide care to the resident during that time.
Findings
The investigation substantiated that a resident (R1) was left unattended in the facility shuttle from 3:00 pm to 8:45 pm due to staff error, resulting in no care being provided during that time. The staff member responsible was dismissed, and civil penalties were assessed.
Complaint Details
The complaint was substantiated. The facility left resident R1 unsupervised in the facility vehicle for several hours. Staff confirmed the incident, and the resident was sent to the hospital for evaluation. The facility did not provide care during the time the resident was left unattended.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility left resident unattended in facility van from 3:00 pm to 8:45 pm, posing immediate health, safety, or personal rights risk. | Type A |
Report Facts
Capacity: 310
Census: 152
Deficiency Type A: 1
Time resident left unattended: 5.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Named in findings related to the incident of resident left unattended |
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 310
Deficiencies: 0
Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not able to adequately care for a resident due to the resident needing a higher level of care, and that a resident assaulted other residents in care.
Findings
The investigation found that although the resident exhibited aggressive behaviors consistent with their medical diagnosis, there was insufficient evidence to substantiate the allegations. Staff were able to provide care and there was sufficient staffing and supervision. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff could not adequately care for a resident due to aggressive behaviors and that the resident assaulted other residents. The resident was hospitalized following an incident involving aggression. Interviews and record reviews indicated behaviors consistent with the resident's diagnosis and sufficient staff response. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 310
Resident census: 150
Number of residents interviewed: 6
Number of staff interviewed: 6
Incident date: Oct 12, 2023
Previous incident date: Sep 20, 2023
Number of Reflections unit staff responding: 4
Number of residents confirming assault allegation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Sep 25, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent a resident from assaulting another resident and that staff handled a resident in a rough manner.
Findings
The investigation included interviews with staff, residents, and a family member, review of records, and a tour of the memory care unit. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff stating they intervened appropriately and residents and family members reporting attentive and caring staff.
Complaint Details
The complaint involved allegations that staff failed to prevent a resident from assaulting another resident and that staff handled a resident roughly. The investigation found no conclusive evidence to substantiate these allegations, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 7
Residents interviewed: 4
Family members interviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and mentioned in findings |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Sep 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted on 09/02/2023 regarding allegations that staff were not providing residents with paid services, admissions agreements, and were not responding to call buttons.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and document reviews showed no discrepancies. Therefore, all allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that staff were not providing residents with services paid for, not providing admissions agreements, and not responding to call buttons. After interviews with staff and residents and review of relevant documents and observations, the allegations were found to be unsubstantiated.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 3
Residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Sep 2, 2023
Visit Reason
An unannounced subsequent required 1-year annual inspection was conducted to review staff and resident files, interview staff and residents, and verify compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Reviews of staff personnel files, resident files, and facility infection control plan found no discrepancies. Liability insurance was current.
Report Facts
Staff files reviewed: 6
Staff interviewed: 9
Resident files reviewed: 10
Residents interviewed: 9
Liability insurance expiration date: Sep 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and file reviews |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Aug 31, 2023
Visit Reason
An unannounced Annual Required Visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents over 60 years old.
Findings
The facility was observed to be clean, well-maintained, and properly equipped with sufficient supplies and safety measures. No deficiencies were cited during this visit.
Report Facts
Residents allowed non-ambulatory: 310
Bedridden residents allowed: 25
Hospice waiver residents: 30
Census: 152
Resident rooms inspected: 8
Resident bathroom sinks tested: 8
Water temperature range: 105
Water temperature range: 120
Perishable food supply: 2
Non-perishable food supply: 7
Walk-in refrigerator temperature: 37
Servers observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst and led facility tour |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced annual required visit and observations |
| Tony Vasallo | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 2
Aug 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not providing reasonable accommodations to a resident in care and that the facility was in disrepair.
Findings
The investigation substantiated both allegations: the facility placed a cognitively intact resident in a memory care unit that did not meet their individual service needs, and the facility experienced repeated flooding and plumbing issues causing unsafe conditions in the resident's room.
Complaint Details
The complaint was substantiated based on interviews, observations, and record review. The allegations included failure to provide reasonable accommodations and facility disrepair. The resident was temporarily relocated to a memory care unit that did not meet their needs, and the facility experienced flooding and plumbing issues in the resident's room.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis, violating reasonable accommodation rights. | Type A |
| Facility had flooding in resident's room caused by plumbing issues, failing to maintain the facility in clean, safe, sanitary, and good repair condition. | Type B |
Report Facts
Capacity: 310
Census: 152
Plan of Correction Due Date: 2023
Plan of Correction Due Date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met during investigation and named in findings regarding facility disrepair and accommodations |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Aug 4, 2023
Visit Reason
The visit was a Case Management - Deficiencies visit conducted on 08/04/2023, stemming from an initial complaint investigation on the same date.
Findings
The facility failed to provide written incident reports within seven days for significant events including a flooding incident that required resident relocation and two resident deaths. These failures threaten the welfare, safety, or health of residents and resulted in cited deficiencies.
Complaint Details
The visit was triggered by an initial complaint investigation on 08/04/2023. Deficiencies were cited related to failure to report incidents timely, including resident relocation due to flooding and two resident deaths.
Deficiencies (2)
| Description |
|---|
| Facility staff failed to provide written incident report within seven days of occurrence for flooding incident causing resident relocation. |
| Facility failed to provide written incident report within seven days of occurrence for deaths of two residents. |
Report Facts
Resident deaths reported: 2
Deficiency type: 1
Plan of Correction due date: Aug 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Visit-Deficiencies and authored the report |
| Kevin Taliaferro | Administrator | Facility administrator met during the visit |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Aug 4, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not providing reasonable accommodations to a resident in care and that the facility was in disrepair.
Findings
The investigation substantiated both allegations: the facility temporarily placed a resident in a memory care unit that did not meet the resident's individual service needs, and the facility experienced plumbing issues causing flooding and A/C problems, indicating the facility was in disrepair.
Complaint Details
The complaint investigation was substantiated. The allegations included failure to provide reasonable accommodations to a resident and facility disrepair. Both allegations were found substantiated based on interviews, observations, and record review.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis, violating reasonable accommodation rights. | Type A |
| Facility failed to maintain clean, safe, sanitary, and in good repair conditions due to plumbing issues and flooding. | Type B |
Report Facts
Facility Capacity: 310
Census: 151
Deficiencies cited: 2
Plan of Correction Due Dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 1
Jun 23, 2023
Visit Reason
The visit was a Case Management Deficiencies inspection conducted on 06/23/2023 stemming from an initial complaint visit on the same date.
Findings
The licensing agency found that the facility failed to submit required written reports within seven days regarding a COVID-19 epidemic outbreak that began on 06/03/2023, during which multiple residents and staff tested positive. Deficiencies were cited for failure to comply with reporting requirements.
Complaint Details
The visit was triggered by a complaint and involved substantiation of failure to report a COVID-19 outbreak timely as required by Title 22 regulations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written reports within seven days of a COVID-19 epidemic outbreak involving multiple residents and staff testing positive. | Type A |
Report Facts
Residents tested positive for COVID-19: 22
Facility staff tested positive for COVID-19: 4
Additional residents tested positive for COVID-19: 13
Capacity: 310
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility administrator present during the inspection and recipient of the report |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Deficiencies visit |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 2
Jun 23, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not following proper COVID-19 mitigation guidance.
Findings
The investigation substantiated that staff failed to adhere to the facility's COVID-19 mitigation plan, including lack of signage limiting visitors, open dining room during an outbreak, staff not wearing masks or gloves as required, and lack of hand sanitizer at COVID-19 positive resident carts.
Complaint Details
The complaint alleged staff were not following proper COVID-19 mitigation guidance. The allegation was substantiated based on observations and interviews during the investigation.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement an Infection Control Plan including staff performing hand hygiene and demonstrating infection control knowledge and skills. | Type A |
| Licensee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19. | Type A |
Report Facts
Capacity: 310
Census: 143
Number of kitchen staff observed not wearing masks: 6
Number of COVID-19 positive resident carts without required hand sanitizer: 4
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met during investigation and exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 310
Deficiencies: 0
Jun 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 12/17/2021 regarding resident care and facility conditions at Morningstar of Pasadena.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including resident injuries, improper meal and medication assistance, unsupervised resident leaving, facility cleanliness, malodor, and delayed response to pendant calls. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents sustaining injury, being left in soiled diapers, lack of proper meal and medication assistance, unsupervised resident leaving, unkempt and malodorous facility, and delayed response to pendant calls. Interviews with staff and residents, review of records, and observations did not support these allegations.
Report Facts
Facility Capacity: 310
Census: 141
Staff interviewed: 6
Residents interviewed: 5
Incontinence care logging frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during investigation |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 0
Jun 12, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that staff financially abused a resident in care.
Findings
The investigation included interviews with the administrator, staff, resident, and resident's Power of Attorney, and a review of the resident's file. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with indications that the financial issue may have involved a private caregiver and not the facility.
Complaint Details
The complaint alleged staff financially abused a resident. The investigation found no sufficient evidence to substantiate the allegation. Resident and POA stated the facility does not handle the resident's finances, and the suspected financial loss may have involved a private caregiver.
Report Facts
Capacity: 310
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kevin Taliaferro | Administrator | Facility administrator who assisted with the investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 310
Deficiencies: 1
May 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not provide resident basic care and assistance, did not provide medication on time, and did not provide water with medication.
Findings
The investigation found the allegations regarding basic care, timely medication, and provision of water with medication to be unsubstantiated due to lack of preponderance of evidence. However, the allegation that the facility did not have sufficient staff to meet resident needs during the overnight shift was substantiated, citing a health and safety hazard when fire personnel could not access the facility due to no staff being present.
Complaint Details
The complaint investigation was triggered by allegations received on 05/08/2023 regarding failure to provide basic care, timely medication, and water with medication. The medication and water allegations were unsubstantiated. The allegation of insufficient staffing during the overnight shift was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have sufficient staff on duty during overnight shift to respond to emergency personnel, resulting in fire department being unable to access facility. | Type A |
Report Facts
Capacity: 310
Census: 131
Staff on overnight shift: 5
Deficiency count: 1
Plan of Correction due date: May 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and named in findings related to staffing and plan of correction |
| Alberto Lopez | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 310
Deficiencies: 0
May 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-17 regarding multiple allegations about resident care and facility conditions at Morningstar of Pasadena.
Findings
The investigation found no substantiated evidence to support the allegations. Staff and residents interviewed denied the allegations, and the Licensing Program Analyst observed no deficiencies or health and safety concerns during the visit. Therefore, all allegations were unsubstantiated.
Complaint Details
The complaint included allegations that residents sustained injuries while in care, were left in soiled diapers for extended periods, did not receive proper meal or medication assistance, were allowed to leave unsupervised, and that the facility was unkempt, malodorous, and slow to respond to pendant calls. All allegations were investigated and found unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 310
Census: 140
Staff interviewed: 6
Residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during inspection |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 144
Capacity: 310
Deficiencies: 0
Apr 28, 2023
Visit Reason
Licensing Program Analyst Galarza conducted an unannounced collateral visit to interview a resident regarding an unrelated complaint at another facility.
Findings
No deficiencies were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the visit and explained the purpose of the visit. |
| Graciela Aquino | Business Office Manager | Participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 310
Deficiencies: 0
Mar 2, 2023
Visit Reason
The visit was an unannounced complaint investigation to determine if staff were properly sanitizing the facility following an allegation received on 12/06/2022.
Findings
Interviews with staff and residents, as well as observations of the dining room and kitchen, indicated that staff were following GI protocols and properly sanitizing the facility. However, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that staff were not properly sanitizing the facility. The investigation included interviews with residents and staff, a tour of the facility, and review of documentation related to GI protocols. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents affected: 4
Residents affected: 5
Capacity: 310
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and named in interviews |
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 310
Deficiencies: 0
Jan 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding improper supervision of residents resulting in falls, improper food storage causing food poisoning, untimely assistance to residents, and untimely meal provision.
Findings
The investigation included interviews with staff and residents, review of documentation, and facility tour. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff and resident interviews and documentation not corroborating the complaints.
Complaint Details
The complaint investigation was triggered by allegations of inadequate supervision leading to falls, improper food storage causing food poisoning, delays in assisting residents, and delays in meal delivery. After thorough investigation including interviews and documentation review, all allegations were determined to be unsubstantiated.
Report Facts
Staff interviews: 8
Resident interviews: 11
Physical therapists available: 3
Staff to resident ratio: 5
Rounds frequency: 2
Food supply duration: 2
Food supply duration: 7
Servers per shift: 4
Wait time for assistance: 5
Wait time for assistance: 30
Meal delivery time: 30
Meal delivery time: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Capacity: 310
Deficiencies: 0
Nov 3, 2022
Visit Reason
An informal virtual meeting was held to discuss the facility's compliance with Pasadena Public Health Department (PPHD) COVID-19 reporting requirements and guidelines, ensuring agreement among CCLD, PPHD, and the facility.
Findings
The facility was reminded of timely COVID-19 case reporting requirements, testing protocols for staff, and submission of daily and weekly reports. The facility agreed to improve reporting and requested testing kits from PPHD.
Report Facts
Capacity: 310
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility representative attending the meeting and involved in compliance discussion |
| Rhonda Guzman | Wellness Director | Facility representative attending the meeting and involved in compliance discussion |
| Bennette Pena | Licensing Program Analyst | Attended the meeting representing licensing agency |
| David Sicairos | Licensing Program Manager | Attended the meeting representing licensing agency |
Inspection Report
Annual Inspection
Census: 133
Capacity: 310
Deficiencies: 0
Oct 7, 2022
Visit Reason
The visit was an annual continuation case management inspection conducted to evaluate compliance with Title 22 regulations and assess various facility components including physical plant, safety equipment, infection control, and resident records.
Findings
The inspection found no deficiencies during both the initial and continuation visits. Various areas including hot water temperatures, medication records, staff and resident files were reviewed and found compliant.
Report Facts
Hot water temperature readings: 114.8
Hot water temperature readings: 113.5
Hot water temperature readings: 114
Hot water temperature readings: 107.5
Hot water temperature readings: 115.6
Hot water temperature readings: 115.4
Hot water temperature readings: 116.2
Hot water temperature readings: 110.1
Medication records reviewed: 8
Staff records reviewed: 8
Resident records reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Business Director | Assisted with the visit and was present during exit interview |
| Bennette Pena | Licensing Program Analyst | Conducted initial and continuation visits |
| Ashley Calderon | Licensing Program Analyst | Conducted continuation visit |
| Rhonda Guzman | Wellness Director | Joined the LPAs during the visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 160
Capacity: 310
Deficiencies: 0
Sep 19, 2022
Visit Reason
An unannounced required 1-year visit focusing on the Infection Control Domain was conducted to evaluate compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were observed during the visit. The facility was found to be operating within compliance, with adequate infection control measures, sufficient food supplies, clean and secure laundry and kitchen areas, and operational fire safety equipment.
Report Facts
Resident rooms: 144
Memory Care residents: 12
Hospice residents: 9
Assisted Living residents: 110
Fire extinguishers per floor: 12
Fire extinguisher last inspection date: May 3, 2022
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Administrator involved in exit interview and facility oversight |
| Graciela Aquino | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Bennette Pena | Licensing Program Analyst | Conducted the inspection visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 117
Capacity: 310
Deficiencies: 0
Jun 10, 2022
Visit Reason
The visit was a follow-up to check the corrections made in the memory care unit after an initial inspection on 2022-05-27.
Findings
The hot water temperature was within the required range, bathroom wall tiles in apartment #206 were repaired, and the smaller outdoor patio was temporarily closed while the larger patio remained available. The newly constructed Memory Care unit meets Title 22 regulations and is ready to serve residents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the visit and stated he will inform LPA when the smaller patio reopens. |
| Cynthia Chan | Licensing Program Analyst | Conducted the follow-up visit and initial inspection of the Memory Care unit. |
Inspection Report
Census: 117
Capacity: 310
Deficiencies: 3
May 27, 2022
Visit Reason
The visit was a case management inspection for the purpose of adding a memory care unit to the facility's plan of operation.
Findings
The inspection found that the memory care unit is located on the 2nd floor with 28 resident bedrooms, but residents' rooms are currently unfurnished. Several issues were identified that must be corrected before licensing, including adjusting hot water temperatures in multiple rooms, repairing bathroom tiles in room #260, and securing side gaps in the outdoor patio.
Deficiencies (3)
| Description |
|---|
| Hot water temperature must be adjusted to read between 105 – 120 degrees Fahrenheit in specified rooms. |
| Room #260 bathroom tiles by the sink must be repaired. |
| The side gaps next to the walls in the outdoor patio must be secured. |
Report Facts
Resident bedrooms in memory care unit: 28
Hot water temperature below 105 degrees: 6
Hot water temperature above 120 degrees: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analysts during case management visit |
| Cynthia D Chan | Licensing Evaluator | Conducted the facility evaluation and signed the report |
| Lisa Hicks | Supervisor | Supervised the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 310
Deficiencies: 0
Apr 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2021-12-29 alleging that staff are not properly trained to provide care to residents.
Findings
The investigation found that staff are fully trained and have more than the required annual hours of training. Interviews with staff and residents confirmed that staff receive ongoing training and are adequately trained to perform their duties. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not properly trained to provide care to residents. The allegation was investigated through interviews with the administrator, 7 staff members, and 11 residents, as well as review of training documentation. The allegation was found to be unsubstantiated.
Report Facts
Capacity: 310
Census: 114
Training hours: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed during the complaint investigation regarding staff training |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 310
Deficiencies: 1
Jan 19, 2022
Visit Reason
An unannounced case management visit was conducted as part of an initial 10-day complaint investigation to assess compliance with health and safety regulations.
Findings
The Licensing Program Analyst observed that upon entering the facility, staff and visitors were not screened for COVID-19, posing an immediate health and safety risk to persons in care. This was found to be a violation of California Code of Regulations, Title 22, Division 6.
Complaint Details
The visit was complaint-related, conducted as an initial 10-day complaint investigation. The deficiency was substantiated as the facility failed to screen for COVID-19 upon entry.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to screen staff and visitors for COVID-19 upon entering the facility, posing an immediate health and safety risk to persons in care. | Type A |
Report Facts
Census: 106
Total Capacity: 310
Deficiencies cited: 1
Plan of Correction Due Date: Jan 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Named in relation to the exit interview and receipt of the report |
| Rhonda Guzman | Wellness Director | Present during the inspection visit |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 310
Deficiencies: 1
Dec 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not complying with local public health department's COVID-19 requirements, specifically failing to submit required weekly documentation.
Findings
The investigation confirmed that the facility failed to submit completed lab reports for twice weekly testing of unvaccinated employees and weekly testing of unvaccinated residents for several weeks between September and November 2021. The Executive Director acknowledged the failure and has delegated staff to ensure timely submission going forward. The allegation was substantiated.
Complaint Details
The complaint was substantiated based on evidence that the facility did not submit required weekly COVID-19 testing reports for unvaccinated employees and residents as mandated by the Pasadena Public Health Department from September to November 2021.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit required weekly lab reports for unvaccinated staff and residents to the Pasadena Public Health Department, posing potential health and safety risks. | Type B |
Report Facts
Capacity: 310
Census: 104
Plan of Correction Due Date: Dec 17, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Acknowledged failure to submit COVID-19 testing reports and delegated staff to ensure compliance |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Census: 104
Capacity: 310
Deficiencies: 0
Dec 7, 2021
Visit Reason
An informal conference was held to discuss the facility's noncompliance with Pasadena Public Health Department guidelines regarding unvaccinated individuals at the facility.
Findings
The facility was not compliant with the requirement to submit weekly reports of unvaccinated employees to the Pasadena Public Health Department and to test unvaccinated staff twice weekly and residents once weekly. No deficiencies were issued during the meeting.
Report Facts
Capacity: 310
Census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to ensuring compliance with weekly reporting and testing requirements |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 0
Sep 15, 2021
Visit Reason
The visit was a pre-licensing inspection to evaluate the facility for initial licensing and ensure compliance with regulations.
Findings
The facility was found to be in substantial compliance with no deficiencies at the time of the pre-licensing visit. Previous deficiencies related to hot water temperature and freezer/refrigerator temperatures were corrected.
Report Facts
Residents' medication logs reviewed: 12
Hospice waiver capacity: 30
Non-ambulatory capacity: 285
Bedridden capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliferro | Executive Director | Met during the pre-licensing visit and exit interview. |
| Rhonda Guzman | Wellness Director | Present during the pre-licensing visit. |
| Cynthia D Chan | Licensing Program Analyst | Conducted the pre-licensing inspection and Component III visit. |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 3
Sep 9, 2021
Visit Reason
The visit was an announced prelicensing evaluation conducted for a Change of Ownership application for a Residential Care Facility for the Elderly for ages 60 years and older.
Findings
The facility was inspected and observed to be a 4-story building with adequate resident rooms and amenities. Some corrective actions were required related to maintaining proper freezer and refrigerator temperatures and hot water temperature. The fire clearance was approved for a capacity of 310 residents.
Deficiencies (3)
| Description |
|---|
| The freezer should be maintained at 0 degrees F. |
| The Refrigerator should be maintained at 40 degrees F. |
| The hot water temperature is measured between 105-120 degree F. |
Report Facts
Capacity: 310
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with LPAs during the prelicensing evaluation and received a copy of the report |
Inspection Report
Original Licensing
Census: 92
Capacity: 310
Deficiencies: 0
Mar 11, 2021
Visit Reason
The visit was conducted as a Component II telephone call with the applicant and administrator to verify identity and confirm understanding of Title 22 regulations as part of the licensing process.
Findings
The applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. They were advised to submit required signed documents and photo ID to the Community Care Licensing analyst.
Report Facts
Capacity: 310
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Guzman | Administrator | Facility administrator participating in the licensing process |
| Kevin Taliaferro | Met with during the visit |
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