Health inspection·April 17, 2025

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, dietary staff interview and document review, the facility failed to ensure staff competency when two of two kitchen staff did not follow manufacturer's instruction when testing the potency of a chemical used to sanitize kitchen cookware. This failure had the potential of cookware not being sanitized and placed residents at health risk. Findings: During a kitchen observation on 4/16/25, at 3:52 p.m., a kitchen staff was asked to test the potency of the sanitizer from the red bucket (standard receptacle containing sanitized solution used to clean food contact surfaces). The kitchen sous chef (SC, second in command of a kitchen) dipped the test strip into the red bucket for less than 5 seconds three times and began reading the results. On the third time the dipping of the test strip was timed and it was 4.97 seconds. During the observation the SC stated the solution was used to sanitize pots and pans. On 4/16/25, at 4 p.m., the registered dietitian (RD) was observed dipping three test strips each for less than five seconds. The temperature of the solution was 142.8 degrees Fahrenheit (temperature scale). When reading the result, the RD questioned a surveyor why the test strip needed to be dipped for 10 seconds. Review of the In-service Program, Dishwashing Procedure, dated 4/3/23, did not indicate the steps required to test the sanitizer from the red bucket. The documentation indicating kitchen staff competence in performing the test correctly was requested and not provided. Review of the Sanitizing Food Contact Surfaces policy, dated January 1, 2020, under red buckets did not outline the correct procedure to test sanitizer potency. During an interview on 4/17/25, at 12:24 p.m., the administrator (ADM) who reviewed kitchen documents stated the staff inservice confirmed staff received training but not comprehension. Review of the sanitizer direction on the container of the test strip indicated to dip paper in quat solution for 10 seconds, testing solution was to be between 65 to 75 degrees Fahrenheit and testing solution should have a neutral pH (pH of 7 is neutral). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 2 of 5 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 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, dietary staff interview and document review, the facility failed to conserve nutritional food value. The cooked food prepared for lunch on 4/14/25 were placed on the steamtable 1 1/2 hours prior to service. This failure had the potential to compromise nutritional quality and palatability of residents who received meals from the kitchen. Residents Affected - Many Findings: Processing and cooking conditions cause variable losses of vitamins. Losses vary widely according to cooking method and type of food. Degradation of vitamins depends on specific conditions during the culinary process, e.g., temperature, presence of oxygen, light, moisture, pH, and, of course, duration of heat treatment (Journal of Food Composition and Analysis, June 2006). The molecular structure of vitamins makes them easily degradable under various conditions such as temperature. During kitchen observation on 4/15/25 beginning at 8:50 a.m., the following cooked food were placed in the steamtable; Tray 1 corned beef, Tray 2 chicken stew, Tray 3 potatoes, and Tray 4 pureed carrots. During an interview at the time of observation on 4/14/25 at 8:50 a.m., the dietary supervisor (DS) stated the food in the steamtable was for lunch and trayline (system of plating food for a meal) began at 10:30 p.m. During an interview on 4/14/25 at 1:04 p.m., the registered dietitian (RD) who reviewed the dietetic service policies stated the lunch food was placed in the steamtable too early. Review of the Dietetic Service - Food Service policy, dated January 1, 2020, indicated to prepare meats just prior to service. Braised or simmered meats may be placed in steam tables for the last 30 minutes of cooking prior to service and it was preferable to steam vegetables as quickly and as close to serving time as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 3 of 5 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 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 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 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, dietary staff interview and document review the facility failed to ensure cooked foods were stored under safe temperatures and failed to cover meats and vegetables in the walk-in refrigerator. The failure of not verifying meat temperatures after blast chilling (rapidly chilling food with cold air) had the potential of causing food borne illness had the foods were not chilled to the correct temperature. The failure of not covering refrigerated foods had the potential to diminish its taste and placed the risk for food contamination. Findings: 1. During kitchen observation with the dietary supervisor (DS) on 4/14/25, at 9:30 a.m., there were food racks approximately five feet in length storing uncovered vegetables and meats of chicken, fish, beef and pork in the walk-in refrigerator. One of the tray contained marked or seared [NAME] broil beef, with four pork chop trays under. Another rack stored raw asparagus, partially cooked onion, bell pepper and eggplant on the top rack, foiled macaroni under followed by slider beef patties. Another rack had four racks of salmon, 6 racks of breaded chicken. There were racks containing trays of chicken and waffles. On the side of the racks there were labels indicating foods were to be consumed on 4/14/25 or 4/15/25. On the shelves were two boxes of uncovered sliced mushrooms. All of the mentioned food items on the racks were not covered. During an interview on 4/14/25, at 10:47 a.m., the registered dietitian (RD) confirmed the [NAME] broil steaks were parbroiled (partially cooked), the chicken, pork, salmon and bacon were raw. During a follow up interview on 4/14/25, at 1:04 p.m., the RD stated when a food is opened it needs to be covered to preserve moisture and prevent contamination. A request was made for the policy addressing the storage of food in refrigerators and not provided by 4/17/25. The 2022 FDA (Federal Drug and Administration) Food Code mandated as specified in paragraph 3-305.11(A)(1) and (2) titled Food Storage indicated food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to dust or other contamination. 2. During an interview on 4/16/25, at 9:33 a.m., the sous chef (SC, the second-in-command in a kitchen) stated the cook marks beef, chicken, and pork by putting it on the grill for 30 seconds to one minute on each side and placing them on the blast chiller to cool. A temperature probe is inserted in the meat and the chiller is set to cool the meat to 33 to 35 degree Fahrenheit (temperature scale). After the chiller stops the meats are placed in the refrigerator and there is no monitoring or temperature log for meats undergoing blast chilling. During an interview on 4/16/25, at 1:30 p.m., the DS stated the blast chiller was acquired a month ago, the temp of the food shows up on the screen. Prior to using the blast chiller food temperatures were checked and the temperatures were recorded on the cool down log. Dietary staff were not checking meat temperatures after blast chilling. Review of the Quick Chill Service and Storage policy, dated January 1, 2020 indicated potentially (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 4 of 5 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 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 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 hazardous food prepared from ambient temperature foods must be cooled to 41 degree Fahrenheit or below within four hours and indicated to measure food temperatures. Review of the undated blast chiller manufacturer instruction did not address the verification of food cooled to proper temperatures. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 5 of 5