complaint·November 25, 2025

On the allegation: Facility kitchen is dirty It was alleged that the facility kitchen is not being maintained in a clean and sanitary condition. During the visit, the LPA conducted a comprehensive tour of the kitchen and dining areas. The following observations were made: A shelf located above the food preparation and hot holding areas had a visible layer of grime. Items stored on this shelf (metal pots, strainers, and plastic containers) were placed upside down, with rims in contact with the surface. A light buildup of grease was observed on top of the oven. Minor food residue was noted under the oven and food prep shelving; however, this was consistent with normal daily kitchen use. All other areas of the kitchen—including the walk-in refrigerator, dry storage, prep counters, and general surfaces—were observed to be clean, well-organized, and maintained in a sanitary condition. While minor cleanliness issues were observed, they did not rise to the level of a systemic or ongoing sanitation concern. The overall condition of the kitchen and dining areas was found to be clean and well-maintained. Based on the limited scope of the observations and the absence of any immediate health or safety risk, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated . On the allegation: Facility has insufficient staff to meet the food service needs of the residents It was alleged that the facility has insufficient staffing to meet residents’ needs related to food preparation and dining room service. During the visit, the LPA observed breakfast and lunch service, conducted staff interviews, attended a discussion with the chef and residents, and reviewed resident council meeting minutes. Based on observations at the time of the visit, staffing levels in the kitchen and dining room during meal periods appeared to be adequate. Resident interviews and those who spoke during the discussion with the chef stated concerns regarding food not being served hot, wait times of 10–15 minutes to place an order, and overall service times ranging from 25 to 45 minutes. Continued on 9099-C Staff interviews reflected mixed feedback. Some staff indicated that meal service runs more efficiently when specific cooks or team members are on duty, suggesting that individual performance impacts overall service quality. Consequently, there are periods when staffing and service delivery are sufficient, and other times when residents may experience delays. Discussions with lead staff, as well as observations of the dialogue between residents and the chef, indicate that the facility is actively working to improve communication, refine procedures, and streamline meal service operations. At this time, concerns regarding food temperature and service delays do not appear to be directly related to staffing levels, but rather to training and process inefficiencies. This was discussed with management during the visit. While the facility was found to be in compliance at the time of the visit, it is recommended that the facility continue to assess staffing patterns and enhance operational processes to ensure consistent and timely meal service. Based on observations and interviews, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . On the allegation: Facility failed to serve meals as planned and posted on the menu It was alleged that the facility does not consistently serve meals as listed on the posted weekly menus. During the visit, LPA reviewed facility menus, both those posted and the revised, "as served menus", interviewed residents and staff, and discussed the facility’s food service system. The facility utilizes a software system called Grove, which is designed to ensure meals meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions. Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, and maintained on file. Menus posted and copies are maintained on file as required. While some residents reported occasional substitutions or not knowing what would be served until arriving in the dining room, the investigation found that, substitutions were infrequent and generally comparable to the originally planned menu items. Per interviews the sides and deserts were the most common changes. Continued 9099-C However, for improved resident satisfaction, it is recommended that the facility enhance communication regarding menu changes—such as posting or announcing substitutions prior to meal service, whenever feasible. Based on a review of the regulation requirements and the facility being in compliance with applicable regulations regarding menu planning and nutritional offerings. This allegation is unsubstantiated at this time. Exit interview conducted, and a copy of this report issued. In the walk-in refrigerator, the LPA initially observed an uncovered container of breakfast sausage links. Upon a second walkthrough, the container had been removed; however, an open, unsealed package of sausage patties was noted. All other food items in the walk-in appeared fresh, no odors or mold was observed and all were properly labeled and covered. In the dry storage room, five food items were found with expiration dates labeled “best by” or “use by” September 2025, indicating they were past their recommended shelf life. Additionally, two packages—one of spaghetti and one of cereal—had visible holes, with food spilling out. A container of raisins, not stored in its original packaging, was covered with plastic wrap that had a hole approximately the size of a quarter. Photographs were taken to document the observed items. These findings are not in compliance Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Section 87555(b)(28), which requires that All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. Based on LPAs observations, the presence of expired and improperly stored food poses a potential health and safety risk to residents. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Report discussed, and copies of appeal rights and reports printed.