Health inspection·July 16, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to maintain a safe and sanitary environment for food storage and food preparation areas by having: Residents Affected - Many 1) Active cockroach (a small scavenging insect capable of spreading bacteria and viruses) infestation in the food preparation area (kitchen). 2) Damaged wall and floor tiles in the kitchen. 3) Food served to residents from facility ' s kitchen after County of Los Angeles Department of Public Health ' s Environmental Health Division (the Authority Having Jurisdiction) had suspended the Public Health Permit. These deficient practices had the potential to result in food contamination and introduce food-borne pathogens (disease causing bacteria and viruses such as e. Coli, Salmonella, norovirus, etc. that can cause vomiting, diarrhea, and other life-threatening complications) spread by cockroaches and affect the health and safety of medically compromised residents for 49 of 49 residents. Findings: During a concurrent observation and interview on 7/5/2023, between 1:52 p.m. and 2:02 p.m., with the District Manager (DM), seven live cockroaches of adult and juvenile (young) life stages were observed throughout the kitchen in the dishwashing area, the mops sink area, and by the clean dish storage area. The DM verbally confirmed that the cockroaches were alive in the kitchen. During an observation on 7/5/23, at 1:54 p.m., a 3.5 by 1 foot area of damaged wall was observed beneath the first compartment of the 3-compartment sink. Three damaged tiles were observed beneath the first compartment (basin used for washing dishes) of the 3-compartment sink. During an observation on 7/5/23, at 2:04 p.m., an accumulation of debris and old food was observed to be encrusted in the interior wall of the dumbwaiter (small elevator used to transport the food between floors of the facility). During an interview on 7/5/23, at 3:14 p.m., with the Food Services Manager (FSM), the FSM stated that the risks associated with cockroaches in a kitchen include cross contamination and issues with spoilage, and the FSM stated that we can ' t have pests going near food and you can ' t have cross contamination. The FSM stated that the clients (CEO and administrators of the facility, as defined by the FSM) know that there is a cockroach problem and that, for the past, however long the pest (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055115 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)