Health inspection·November 21, 2019

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions when food in dry storage was undated and beyond the discard date. This failure had the potential to result in food borne illness. Findings: During an observation on 11/18/19 at 8:30 a.m., an opened and undated bottle of sesame oil was in the dry storage. During an interview on 11/18/19 at 8:30 a.m., the Dietary Manager (DM) stated the bottle of sesame oil should have had a label with the date written on it when it was opened. DM stated she would immediately throw the bottle of sesame oil out. During an observation on 11/18/19 at 8:30 a.m., an opened bottle of [NAME] cooking wine dated 3/7/19 was kept in the dry storage. During an interview on 11/18/19 at 8:30 a.m., DM stated the 3/7/19 date indicated the bottle was opened on 3/7/19. She stated the bottle should have been discarded on or before six months after it was opened. DM stated the bottle was beyond the discard date and she would immediately throw it out. A record review of the undated policy and procedure titled, LABELING AND DATING OF FOOD indicated all products must be clearly labeled with the date when the product was opened. Page 1 of 3 055276 055276 11/21/2019 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had seven resident Rooms (27, 28, 29, 30, 31, 32, and 34) with multiple beds that provided less than 80 square feet per resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for the storage of the residents' belongings. Findings: During an observation on 11/20/19 at 8:55 a.m., the following rooms and corresponding square footage (sq. ft.) per bed were identified. Room Activity Size 27 215.66 sq ft 71.88 sq ft/bed 28 212.40 sq ft 70.80 sq ft/bed 29 212.40 sq ft 70.80 sq ft/bed 30 215.66 sq ft 71.88 sq ft/bed 31 215.66 sq ft 71.88 sq ft/bed 32 213.93 sq ft 71.31 sq ft/bed 34 303.75 sq ft 75.93 sq ft/bed During an interview on 11/20/19 at 9:11 a.m., Resident 3 stated that he liked his room. He stated his room was large enough and he could maneuver his wheel chair in his room. During an interview on 11/20/19 at 9 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated he had worked many times with residents in Rooms 27-32 and room [ROOM NUMBER], and the rooms were large enough to move around and provide care. During an interview on 11/20/19 at 9:05 a.m., the Certified Nursing Assistant 1 (CNA 1) stated she had worked many times with residents in Rooms 27- 32 and room [ROOM NUMBER], and the rooms were large enough to move around in and provide care. During an interview on 11/20/19 at 9:06 a.m., Licensed Resource Nurse 1 (LRN 1) stated she had worked many times with residents in Rooms 27 - 32 and room [ROOM NUMBER], and the rooms were large enough to move around in and provide care. During random observations of care and services from 11/18/19 to 11/21/19, there was sufficient space for the provision of care for the residents in Rooms 27 - 32 and 34. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal 055276 Page 2 of 3 055276 11/21/2019 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0912 Level of Harm - Potential for minimal harm space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the seven rooms. The Department recommends granting the room size waiver. Residents Affected - Some 055276 Page 3 of 3