Health inspection·August 22, 2019

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 facility document review, the facility failed to label and store food under sanitary conditions when: Residents Affected - Some 1. Five containers of strawberries had white fur on them. Three bananas had black and yellow skin. 2. One loaf of open large wheat bread was without a date. 3. Five small white bowls, two medium bowls two scoops with green handles were stacked and placed in the cabinet with water sitting in them. 4. Registered Dietician (RD) came into the kitchen and did not immediately wash her hands and completely cover her hair. These failures had the potential to cause food contamination and food borne illness in residents. Findings: 1. During an observation on and concurrent interview 8/21/19 at 8:05 a.m., in the walk in freezer, in a box there were five containers of strawberries with white fur on them dated 8/16/19. In the dry storage area, there were three bananas with black and yellow skin . The Dietary Manger (DM) stated fruit is kept three to five days. A review of the policy and procedure titled Storing Produce , dated 2018, indicated to check boxes of fruit and vegetables for rotten or spoiled items. Throw away all spoiled items. A review of the Produce Storage Guidelines dated 2018' indicated strawberries should be stored in the refrigerator two to three days A review of the policy titled Corrective Action When Food in the Store Room Reaches Above 85F undated, indicated bananas will ripen faster in higher heat and should be checked that they have not become soft, moldy or bruised. Discard spoiled bananas. 2. During an observation and concurrent interview on 8/21/19 at 8:05 a.m., one loaf of large wheat bread in the standup freezer was open without a date. The Dietary [NAME] (DC) stated when the bread was opened, it should have been dated. A review of the policy and procedure titled , General Receiving of Delivery of Food and Supplies, (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: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550 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)