Health inspection·August 28, 2025

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. §72523. Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/11/2025 the California Department of Public Health received a complaint alleging roaches were found in the facility's kitchen. On 7/11/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. CDPH determined the facility had a roach infestation. The facility failed to: 1. Ensure the facility kitchen was free from cockroaches. 2. Follow their Policy and Procedure (P/P), titled, "Pest Control" dated 5/2008, that indicated the facility maintains an ongoing pest control program to ensure the building is kept free from insects and rodents. As a result, these deficient practices resulted in the facility's kitchen closure for use and food preparation for the residents and placed 44 residents at risk to consume potentially contaminated food with bacteria and viruses that causes illness. During an observation on 7/11/2025 (eight days after the facility was treated for general pest control [GPC]), at 2:19 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of white powdered thickener that was inside an open plastic bag. During an observation on 7/11/2025, at 2:26 p.m., of the facility's dry food storage area in their kitchen, in the presence of the DSS, a medium sized dark brown cockroach was seen running out of a box of individually packaged crackers. A review of the facility's Pest Control Invoice dated 5/12/2025, indicated the facility treated Resident 1's room for roaches. A review of facility's Pest Control Invoice dated 5/20/2025, indicated the facility treated Resident 1's room for American roaches (water bugs). A review of facility's Pest Control Invoice dated 5/28/2025, indicated the facility treated Resident 1's room for American roaches. A review of the facility's Pest Control Invoices dated 6/3/2025, 6/25/2025, and 7/3/2025 (eight days before roaches were found in the facility's kitchen) indicated, the facility's interior kitchen was treated for GPC, there was good preparation and it was very clean interior, there were no insects/live insects witnessed during the treatment, the whole kitchen was treated using a liquid residual pesticide (a substance or mixture intended to prevent, destroy, repel, or mitigate any pest) spray and the kitchen was in good condition. The invoices indicated the exterior perimeter of the property was treated using a liquid residual pesticide, including window frames, door frames, dumpster areas, and all cracks and crevices. No insects were witnessed during treatment of either areas. During an interview on 7/11/2025 at 2:38 p.m., the Dietary Supervisor (DS) stated the thickener plastic bag should have been closed as part of their infection control practices to prevent bugs from getting inside. During an interview on 7/11/2025 at 2:40 p.m., Dietary Aide (DA) 1 stated approximately one month ago (June), she noticed a few small roaches on different occasions in the dry storage area and informed the DS to notify pest control. DA 1 stated pest control came twice in the past month to treat the area. During an interview on 7/11/2025 at 2:44 p.m., the DS stated she had not been informed by anyone that cockroaches were seen in the kitchen, and she had not seen any herself. During an interview on 7/15/2025 at 10:02 a.m., with randomly selected Resident 1, Resident 1 stated approximately one month ago he saw two big roaches in his room but had not seen any since then. During an interview on 7/11/2025 at 12 p.m., the Director of Nursing (DON) stated she had worked at the facility for three years and was not aware there were roaches in the building. The DON stated she found out today (7/11/2025) there were roaches found in the kitchen when the environmental health department came to the facility at approximately 12 p.m. and pointed them out to the DSS. The DON stated the environmental health department staff used a flashlight, tapped firmly on a wood shelf in the kitchen and two roaches measuring about one and a half inches came out During review of facility's Policy and Procedure (P/P) titled "Pest Control" dated 5/2008, the P/P indicated the facility maintains an on-going pest control program to ensure that the building is kept free from insects and rodents. The facility failed to: 1. Ensure the facility kitchen was free from cockroaches. 2. Follow their P/P, titled, "Pest Control" dated 5/2008, that indicated the facility maintains an ongoing pest control program to ensure the building is kept free from insects and rodents. As a result, these deficient practices resulted in the facility's kitchen closure for use and food preparation for the residents and placed 44 residents at risk to consume potentially contaminated food with bacteria and viruses that causes illness. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.