Health inspection·February 6, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 follow proper sanitation and safe food handling, in accordance with the facility's policy and procedures on Sanitation and Infection Control, by failing to ensure: 1. Main [NAME] 1 changed gloves while plating lunch, picked up paper from the floor, and proceeded to touch the parsley garnish with same plastic gloves. 2. Kitchen Assistant 1 and Kitchen Assistant 2 were observed not wearing hair net properly, exposing hair during breakfast preparation. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: On 2/06/2024 at 12:15 PM, during an observation of lunch preparation, [NAME] 1 was observed wearing plastic gloves, grabbing paper lunch slip, dropping paper lunch slip on the floor and picking it up, then grabbed parsley garnish wearing the same gloves and place garnish over a resident plated rice. On 2/06/2024 at 12:18 PM, during a subsequent interview with the DS, the DS stated all staff should always change gloves when preparing and handling food especially if they pick up something from the floor to prevent cross contamination. On 2/07/2024 at 6:50 AM, Kitchen Assistant 1 was observed entering the kitchen putting on a hair net covering only the top of the hair leaving exposed the lower half of Kitchen Assistant 1 ' s backside of head hair. Kitchen Assistant 1 was further observed walking over to the breakfast preparation area and assisted [NAME] 1 with the oatmeal. On 2/07/2024 at 7:18 AM Kitchen Assistant 2 was observed not wearing a hair net and was only wearing a paper hat covering the top of the head, leaving the lower half of the backside of the head hair, while assisting with breakfast plating. On 2/07/2024 at 7:20 AM, during a concurrent interview with the DS, the DS stated it was important for all kitchen staff to always wear a hair net that covered all parts of the hair while in the kitchen to avoid hair contaminating any food item in the kitchen. (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 2 Event ID: 055181 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 055181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770 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)