Health inspection·September 18, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gravy.During a concurrent observation and interview on 9/18/2025 at 12:53 pm, with [NAME] 1, inside the kitchen, [NAME] 1 was observed making more gravy at the stove. [NAME] 1 stated, I'm making more gravy because I ran out.During an observation on 9/18/2025 at 12:56 pm, inside the kitchen, [NAME] 1 was observed serving gravy to residents' trays. The temperature of the gravy was not checked before [NAME] 1 served the gravy to residents.During an observation on 9/18/2025 at 1:05 pm, inside the kitchen, [NAME] 1 was observed serving fish at the tray line. [NAME] 1 stated the fish was made for residents who did not eat pork. [NAME] 1 removed the fish from the stove and served it to a resident's tray. The temperature of the fish was not checked before serving.During a concurrent interview and record review on 9/18/2025 at 2:05 pm, with DA 1, the FTLS and Refrigerator and Freezer Temperature Log (RFTL) for 9/2025 were reviewed. DA 1 stated, As you can see, we haven't checked the fridge and freezer temperatures since 9/3/2025. DA 1 stated the morning cook (for breakfast) was supposed to check the temperatures of the fridges and freezers. DA 1 stated, We haven't been good about checking the temperatures of the tray line items. It's been inconsistent all month. There are a lot of meal (temperatures) missing. DA 1 stated DA 1 accidentally logged the temperatures on the FTLS that were supposed to be for lunch today on 9/17/2025.During a concurrent observation and interview on 9/18/2025 at 2:08 pm, inside the kitchen, with DA 3, the temperature of freezer 2 was observed. DA 3 stated freezer 2 was used to store ice cream and frozen dessert. DA 3 stated the temperature of freezer 2 was 10 degrees F. DA 3 stated DA 3 did not know what the temperature of freezers was supposed to be. DA 3 stated, The morning team, was supposed to check freezer and fridge temperatures.During a concurrent observation and interview on 9/18/2025 at 2:15 pm, inside the kitchen, with DA 3, temperature of fridge 1 was observed. DA 3 stated fridge 1 was used to store dairy products and eggs. DA 3 stated the temperature of fridge 1 was 43 degrees F. DA 3 stated, I don't know what the temperature is supposed to be.During a concurrent observation and interview on 9/18/2025 at 2:19 pm, inside the kitchen, with the covering Dietary Service Supervisor (DSS), fridge 1 and freezer 2 were observed. The covering DSS stated the temperature of fridge 1 was 43 degrees F. The DSS stated the temperature of fridges was supposed to be at 35 degrees F to ensure the food inside did not get spoiled. The covering DSS stated the temperature of freezer 2 was 10 degrees F. The covering DSS stated, We don't know the appropriate temperature because the internal thermometer reads 10 degrees F and the external thermometer reads negative four (-4) degrees F.During a concurrent observation and interview on 9/18/2025 at 4:38 pm, inside the kitchen, with the covering DSS, the temperature of milk inside fridge 1 was observed. The DSS opened a gallon container of whole milk from fridge 1. The temperature of the milk registered at 45 degrees F. The covering DSS stated, It's (the milk) is not safe to serve to residents. The covering DSS stated residents were served milk for lunch from fridge 1 and did not know how long the temperature of fridge 1 and the milk inside fridge 1 were not at the appropriate temperature.During an interview on 9/18/2025 at 3:46 pm, with the Registered Dietician Consultant (RDC), the RDC stated the fridge and freezers temperatures were supposed to be checked twice a day in the morning and evening. The RDC stated if the internal and external thermometers of the fridges and freezers did not match, staff needed to report the issue to dietary supervisor and have maintenance check the temperatures to determine where the discrepancy is from. The RDC stated if staff are not checking the temperatures of fridges and freezers then staff would not know there is a temperature problem with the appliances. The RDC stated if a fridge temperature was 43 degrees F and a freezer temperature was 10 degrees F it was not safe to serve the food inside them. The RDC stated these temperatures could affect the food safety of the items inside and there was potential for spoilage and lack of freshness of the food. The RDC stated, The [FTLS] has a lot of missing days for September. The RCD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 2 of 3 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated the cook should check the temperature of any food item before it goes on a resident's tray before serving. The RDC stated temperatures were checked primarily for hot and cold food and items that were on the steam table. The RDC stated that milk, gravy, and fish temperatures were supposed to be checked before serving to residents to ensure food was cooked to the appropriate temperature and that cold food was being served at the appropriate temperature and not within the danger zone (the range between 40 degrees F and 140 degrees F where harmful bacteria can grow rapidly on food, increasing the risk of foodborne illness). The RDC stated this put residents at risk for food borne illness. The RDC stated gravy should be kept in the steam table because gravy was a hot food item.During an interview on 9/18/2025 at 5:02 pm, with the Director of Nursing (DON), the DON stated it was important to check the temperature of food being served to residents and to ensure the food was at the appropriate temperature for palatability (taste) so residents did not get sick. The DON stated if food was not served at the appropriate temperature residents could develop food borne illness and sick with vomiting, diarrhea, develop dehydration and even require hospitalization. The DON stated if the fridges and freezers were not kept cold enough then the food in them would need to be thrown away because the residents could develop food borne illness and get sick from the food kept in those fridges and freezers.During a review of the facility's P&P titled, Daily Food Temperature Control, revised 8/2019, the P&P indicated the temperature of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log (FTLS). The P&P indicated this was done to ensure that food is safe and served within the appropriate temperature. The P&P indicated the cook and/or dietary aide shall take the temperature of the food prior to meal service. The P&P indicated all hot foods shall be cooked to proper temperature and held for service at temperatures at 140 degrees F or above. The P&P indicated all cold foods shall be held for service at temperatures 40 degrees F or below.During a review of the facility's undated P&P titled, Refrigerator/Freezer Storage, the P&P indicated dietary staff would check and record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate temperature for food storage and handling. The P&P indicated dietary staff would check the inside temperature of refrigerators and freezers.record and initial the temperature log at the beginning of the shift. The P&P indicated if temperatures were not within appropriate range, dietary staff would notify the dietary supervisor and/or maintenance supervisor and administrator. The P&P indicated refrigerator temperature should be at 40 degrees F or lower and freezer temperature at zero (0) degrees F or lower.During a review of the facility's undated P&P titled, Food Preparation Policy, the P&P indicated all meals.must comply with regulatory compliance. The P&P indicated all food prepared would be prepared by methods that preserved.proper temperature. Event ID: Facility ID: 055126 If continuation sheet Page 3 of 3