Health inspection·August 5, 2025

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 ensure the food service area was maintained clean, sanitary, and in a functional manner while providing proper food handling in accordance with the facility's policy and procedure (P&P) by failing to ensure:1. Walk in freezer's temperature was checked on 8/4/2025 and 8/5/2025, Walk in refrigerator's (Refrigerator 1) temperature was checked on 8/4/2025 and 8/5/2025 and Standing refrigerator's (Refrigerator 2) temperature was checked on 8/2/2025, 8/3/2025, 8/4/2025 and 8/5/2025.2. Dishwasher machine's top surface was clean, without dust and crumbs. 3. [NAME] crispies were disposed after 6/30/2025 as labeled in the use by date sticker and flour with prepared date of 6/14/2025 was labeled with correct use by date.4. The dry food storage room's temperature was checked daily from 7/20/2025 to 8/5/2025. 5. 208 nutritional supplement drinks (designed to help individuals gain or maintain weight and used as meal replacements) were not stored in a room with temperature of 90 Fahrenheit (F, unit of measurement). 6. 52 packs of loaf bread were not stored in a room with temperature of 90 F. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) and can lead to other serious medical complications and hospitalization.1.During a concurrent observation in the facility kitchen and record review on 8/5/2025 at 6:15 AM, of walk-in freezer and Refrigerator 1 temperature log dated for the month of August 2025 were reviewed. Observed Refrigerator 1 and walk- in freezer had a record of walk- in freezer and Refrigerator 1 temperature log posted outside the door. Walk in freezer and Refrigerator 1 has missing temperatures and initials for 8/4/2025 for the PM (afternoon shift) column and has missing temperatures and initials for 8/5/2025 AM (morning shift) column. The logs also indicated AM shift cook to check temperatures upon arrival in the morning and PM shift cook to check temperatures before leaving at night. During a concurrent observation and record review on 8/5/2025 at 6:17 AM in the facility kitchen, Refrigerator 2's temperature log for the month of 8/2025 was reviewed. Observed Refrigerator 2's temperature log posted outside the door. The temperature log did not indicate AM and PM temperatures and initials on 8/2/2025, 8/3/2025, 8/4/2025. In addition, the temperature log did not have documentation of temperature and initials on 8/5/2025 under the AM shift column. During an interview on 8/5/2025 at 1:37 PM with [NAME] 1, [NAME] 1 stated he forgot to check the temperatures of the walk-in freezer, Refrigerator's 1 and 2 today when he started his shift and entered Facility's kitchen at 5 AM. During an interview on 8/5/2025 at 1:40 PM with [NAME] 2, [NAME] 2 stated she worked last night, and forgot to check the temperature of the walk in freezer, Refrigerators 1 and 2 when she left the kitchen at 6:30 PM. [NAME] 2 stated it is important to check temperatures of the freezer and refrigerators before end of shift during the PM to make sure the foods are being stored safely and to avoid having food spoilage that is not beneficial to residents. During an interview on 8/5/2025 at 1:57 PM with the Dietary Services Supervisor (DSS), the DSS stated it was Cook's responsibility to check and document the Page 1 of 3 055341 055341 08/05/2025 Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some freezer and refrigerator's temperature. The DSS stated it is important to check and maintain the correct freezer and refrigerator temperature to avoid foodborne illnesses, bacteria might grow if the temperature is not maintained, and it is not safe for the residents who will consume the foods that spoiled or not stored in the correct temperature settings. During a review of Facility's P&P titled Sanitation and Infection Control Refrigerated Storage, dated 2018, indicated refrigerator temperatures should be recorded two times each day. The P&P indicate it is recommended temperatures be recorded in AM immediately after opening the kitchen and the PM before closing. During a review of Facility's P&P titled Food Receiving and Storage, revised in November 2022, indicated functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the designee and documented. 2. During an observation on 8/5/2025 at 6:30 AM in the facility's kitchen, the dishwasher machine top area was observed with dust and crumbs. During a concurrent observation and interview on 8/5/2025 at 8:44 AM in the facility's kitchen with the DSS, the dishwasher machine was observed. The DSS stated the top area of the dishwasher machine appears to be dirty with dust and crumbs. The DSS stated the dishwasher machine should be cleaned every after use. The DSS stated, since this is the first time that the dishwasher machine was being used after breakfast meal, the dishwasher machine should have been cleaned by last night's kitchen staff who last used the dishwasher after dinner meal. During an interview on 8/5/2025 at 1:33 PM with Kitchen Staff 1 (KS 1), KS 1 stated that the dishwasher machine was dirty this morning and only noticed it when the DSS told him to clean it after being observed by surveyor. KS 1 stated the dishwasher machine's outer area should remain clean to avoid having the cleaned dishes from getting dirty from dust and crumbs. During a review of Facility's P&P titled Sanitation and Infection Control - Sanitizing Equipment, Food and Utility Carts, dated 2011, indicated the following: All equipment should be sanitized to prevent the spread of disease and infection. All kitchenware equipment (including utensils and plates) and surfaces which come in contact with food will be cleaned and sanitized after each use. 3. During an observation on 8/5/2025 at 6:21 AM in the facility's kitchen dry food storage room, a container of rice crispies (toasted rice grains) were observed with preparation date of 1/30/2025 and use by date of 6/30/2025. In addition, there was a container of flour labeled with preparation date of 6/14/2025 and use by date of 7/14/2025. During an interview on 8/5/2025 at 1:41 PM with [NAME] 2, [NAME] 2 stated the container of rice crispies should have been thrown right after 6/30/2025 and not wait until more than a month. [NAME] 2 stated it is no longer safe to serve the residents food items that have passed by the used by date because it might cause sickness like stomachache and possible diarrhea to the residents. During an interview on 8/5/2025 at 1:42 PM with [NAME] 2, [NAME] 2 stated the flour used by date was mislabeled. [NAME] 2 stated flour can stay in the container for up to 5 months. [NAME] 2 stated, since the flour was labeled as prepared on 6/14/2025, the use by date should be 11/14/2025 and not 7/14/2025. [NAME] 2 stated having a mislabeled used by date might cause confusion to kitchen staff, and untimely disposing might happen if foods were labeled incorrectly. During a review of Facility's P&P titled Food Receiving and Storage, revised in November 2022, indicated dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). During a review of Facility's P&P titled Food Storage Guidelines: Dry Storage, dated 2020, indicated the following shelf life: Flour: (opened) 6-8 months. 4. During a concurrent observation and interview on 8/5/2025 at 2:24 PM in the facility's dry food storage room with DSS, the room was observed to be warm, and the wall thermometer indicated 90 F. The DSS stated it is hot in the room because the swamp cooler was turned off. The DSS stated 90 F is not a good temperature for the dry food storage room. The DSS stated the room should maintain a temperature of 70 F or below. During a concurrent 055341 Page 2 of 3 055341 08/05/2025 Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some record review and interview on 8/5/2025 at 2:27 PM in the facility's dry food storage room with DSS, the food storage temperature chart for the month of July 2025 was reviewed. The DSS stated, per chart, the last time the dry food storage room was checked for temperature was on 7/19/2025. The DSS was unable to provide written evidence of the dry food storage room temperature chart for August 2025. The DSS stated the temperature check and documentation was not done from 7/20/2025 to 8/5/2025, because if it was done, the temperature chart should have been posted outside the door of dry food storage room. During a concurrent observation and interview on 8/5/2025 at 3 PM with the Director of Nursing (DON), in the facility kitchen's dry food storage room, the thermometer was observed at 84 F. The DON verified and stated, the room is warm, and it is not good for the foods that are stored inside the dry food storage room. During a review of Facility's undated form titled Food Storage Temperature Chart, indicated recommended temperature for dry storage area is 50 F - 70 F. During a review of Facility's P&P titled Food Receiving and Storage, revised in November 2022, indicated non-refrigerated foods are stored in temperature and humidity-controlled room. 5. During a concurrent observation in the facility's dry food storage room, record review and interview on 8/5/2025 at 3:02 PM with the DSS, the facility's undated Policy and Procedure (P&P) for Boost and Nepro was reviewed. The dry food storage room thermometer was observed at 84 F. In addition, approximately 176 bottles of Boost (nutritional supplement drink) and approximately 32 containers of Nepro (nutritional supplement drink specifically designed for individuals on dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) were observed. The P&P indicated storage temperature: Store in a cool, dry place, ideally between 68 F and 77 F. The DSS stated storing boost, ensure and Nepro in a room with temperature of 84 F can lead to spoilage of the drinks and will give the residents health issues like diarrhea. The DSS stated the quality of the food or drink is no longer the same when stored beyond the ideal temperature of 77 F. 6. During a concurrent observation in the facility's dry food storage room, record review and interview on 8/5/2025 at 3:35 PM with DSS, the facility's undated P&P for loaf bread storage was reviewed. Observed multiple loaf breads were stored on a food rack inside the room and thermometer was observed at 84 F. the P&P indicated storage for loaf bread, the room temperature should be within the 60 F to 80 range. The DSS stated, the loaf bread is no longer good to serve to residents since the dry food storage room reached 90 F today. During a concurrent observation and interview on 8/5/2025 at 3:40 PM with the Administrator (ADM), the Facility's dry food storage room was observed. The ADM verified the room feels warm. The ADM stated the nourishment drinks and loaf bread that were stored in the dry food storage room are no longer good to serve to the residents. During a review of Facility's P&P titled Food Receiving and Storage, revised in November 2022, indicated food services, or other designated staff, always maintain clean and temperature appropriate food storage. 055341 Page 3 of 3