Inspection·June 12, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 food safety practices to prevent foodborne illnesses for eleven out of eleven residents, when food debris and a cup of apple sauce were observed under the kitchen stove. This failure had the potential to result in food contamination by attracting insects and rodents that can spread pathogenic microorganisms (germs which can cause diseases) to residents through food prepared in the facility kitchen. Findings: During a review of the facility's census (a periodic count of the facility's population), titled, (Name of facility), dated June 10, 2024, the facility census indicated there were eleven residents admitted to the facility. During a concurrent observation and interview on June 10, 2024, at 8:13 AM with the Registered Dietitian (RD- experts in the disciplines of food and nutrition) and Kitchen [NAME] (KC) inside the facility kitchen, there were food debris and a cup of apple sauce observed under the kitchen stove. The KC stated the floor should be kept clean and free from debris or food items. During a concurrent observation and interview with the Dietary Supervisor (DS) on June 11, 2024, at 11:45 AM, inside the kitchen during tray line (a system of food preparation used in facilities), the DS was observed preparing lunch trays for residents. The DS stated food services for all residents were prepared in the kitchen. During an interview on June 12, 2024, at 10:07 AM with the RD, the RD stated the kitchen area should always be kept clean, including the undersides of equipment. The RD stated the food debris and cup of apple sauce under the stove had the potential to attract insects, rodents, and pests. During a concurrent interview and record review on June 12, 2024, at 11:08 AM, with the Assistant Administrator (AA), the facility's policy and procedure (P&P) titled, Cleaning and Sanitation of Dining and Food Service Areas, modified 2022, was reviewed. The P&P indicated, Policy: The food and nutrition service staff will maintain the cleanliness and sanitation of the dining and food service areas . The AA stated the expectation the kitchen will be maintained clean was not met and the facility policy was not followed. A review of the Food and Drug Administration Federal Food Code 2022, 4-402.12 titled, Fixed Equipment, Elevation or Sealing, indicated, The inability to adequately or effectively clean areas under (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: 555592 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 555592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Transitional Care 1575 Bishop Street San Luis Obispo, CA 93401 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)