Other·October 25, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health for the investigation of one complaint during an Abbreviated survey. Complaint Number: CA00602402 Representing the Department of Public Health: Dietary Consultant ID No. 38740 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00602402. Highest Severity and Scope: L Immediate jeopardy was called on September 4, 2018 at 5:55 p.m. The facility administrator, Director of nursing and dietary services supervisor was notified of the immediate jeopardy situation. The Facility administrator and other staff present were informed of the cracks on the walls behind the dirty area sink next to the dish machine, holes under the dirty area sink, foam sealants covering under the sinks, and plywood that was holding up the sinks. The facility was also informed of lack of a consistent communication between kitchen and maintenance regarding presence of roaches in the kitchen and lack of aggressive action to control the harborage of cockroaches. An acceptable plan of action was accepted on September 4, 2018 at 7:20 p.m., the plan of action-included kitchen will remain closed due LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to infestation, no food will be processed in the kitchen and all open food items will be discarded. Meals for residents will be delivered from sister facility and nearby restaurants and served to residents. Disposable trays, plates and utensils will be used. Deep cleaning of the kitchen floors and other surfaces to remove build-up of grease, grime and other debris. Disinfection of the kitchen floors with bleach, disinfection of equipment would be conducted in the evening. Pest Control Company will begin aggressive management this evening and perform several treatments to exterminate the cockroaches. Plumbers were contacted to clean drains. Maintenance technician to clean and remove plywood and foam sealants under the sinks and outside contractor to cover holes and cracks with cement and metal support for the sinks. Registered Dietitian to conduct in services to dietary staff and nursing staff regarding sanitation, food handling and reporting system for pests. New systems to be established for reporting, monitoring and auditing sanitation including pests in the kitchen. The immediate jeopardy was abated on September 6, 2018 at 8:15 a.m., when the surveyor verified that the facility's plan of action was implemented. The Administrator, Director of Nurses and Dietary Supervisor were notified..

F812 SS=L Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 10/25/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record review, the facility failed to ensure that food was stored in accordance with professional standards for food service safety when the facility failed to eradicate cockroach population and eliminate harborage conditions in the kitchen. The facility's kitchen environment including three (3) of three floor drains directly connected to sewer line, cracks in the walls, broken grouts between the floor tiles, foam sealants under the sinks and plywood pieces that holds the sink in place, provided both food and safe places for harborage of pests and the warm kitchen conditions necessary to encourage the cockroaches to thrive. In addition, lack of an effective reporting and communicating system regarding the presence of cockroaches in the kitchen delayed proper treatment to control harborage. These deficient practices had the potential to cross-contaminate food that could cause food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE borne illness in 85 of 85 residents who received food from the kitchen. Cockroaches' saliva, droppings, and decomposing roaches' bodies contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Cockroaches are capable of carrying disease causing organisms such as Salmonella typhimurium (is a type of bacteria that cause food poisoning), typhoid fever (an infectious bacterial fever with an eruption of red spots on the chest and abdomen and severe intestinal irritation), Entamoeba histolytica (a parasite that is transmitted to humans via contaminated water and food), poliomyelitis virus (a virus that enters the mouth and spreads from person to person and can invade an infected person's brain and spinal cord, causing paralysis), Staphylococcus spp (a bacteria that cause skin infections), Streptococcus spp (a bacteria that cause diseases such as sore throat), hepatitis virus (inflammation of the liver), and coliform bacteria (a bacteria found in water causing diseases). Immediate jeopardy was called on September 4, 2018 at 5:55 p.m. The facility administrator, Director of nursing and dietary services supervisor was notified of the immediate jeopardy situation. The Facility administrator and other staff present were informed of the cracks on the walls behind the dirty area sink next to the dish machine, holes under the dirty area sink, foam sealants covering under the sinks, and plywood that was holding up the sinks. The facility was also informed of lack of a consistent communication between kitchen and maintenance regarding presence of roaches in the kitchen and lack of aggressive action to control the harborage of cockroaches. An acceptable plan of action was accepted on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE September 4, 2018 at 7:20 p.m., the plan of action-included kitchen will remain closed due to infestation, no food will be processed in the kitchen and all open food items will be discarded. Meals for residents will be delivered from sister facility and nearby restaurants and served to residents. Disposable trays, plates and utensils will be used. Deep cleaning of the kitchen floors and other surfaces to remove build-up of grease, grime and other debris. Disinfection of the kitchen floors with bleach, disinfection of equipment would be conducted in the evening. Pest Control Company will begin aggressive management this evening and perform several treatments to exterminate the cockroaches. Plumbers were contacted to clean drains. Maintenance technician to clean and remove plywood and foam sealants under the sinks and outside contractor to cover holes and cracks with cement and metal support for the sinks. Registered Dietitian to conduct in services to dietary staff and nursing staff regarding sanitation, food handling and reporting system for pests. New systems to be established for reporting, monitoring and auditing sanitation including pests in the kitchen. The immediate jeopardy was abated on September 6, 2018 at 8:15a.m., when the surveyor verified that the facility's plan of action was implemented. Findings: On September 4, 2018, at 4:20 p.m., an unannounced visit was conducted to the facility to investigate a complaint from Los Angeles County Public Health Environmental Health Department surveyor regarding the notice of facility kitchen closure due to vermin infestation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation of the kitchen on September 4, 2018, at 4:30 p.m., the kitchen was closed with the notice of closure from Department of Public Health posted on the door. The facility was given 48 hours to eradicate roaches from the kitchen. The kitchen was inspected for the presence of cockroaches. There was one large dead cockroach and two small dead cockroaches observed in the back corner on the floor under the dish machine. Located adjacent to the dish machine was a sink for dirty dishes and underneath the sink, cracks and holes were observed. Cracks under the sink and holes in the wall were partially covered by plywood and foam sealant. There were holes in the grout between floor tiles and the three floor drains has with no cover. During a concurrent interview on September 4, 2018, at 4:30 p.m., with the Dietary Supervisor (DS), she stated that she has seen roaches off and on but not a lot maybe once a month and always under the dirty dish area sink and the dish machine. DS stated that this morning the facility has notified the maintenance manager about the cracks and holes on the wall behind the sink and under the sink. DS stated that she reports pest issues to maintenance supervisor during morning staff meeting and the maintenance supervisor is the one who calls the pest control. During an interview with Cook 1 on September 4, 2018, at 4:50 p.m., Cook 1 stated that she sees roaches in the morning when she enters the kitchen. Cook 1 stated that she first kills the roach then alerts her coworkers that there are roaches around and to be careful not to get in food. She also stated that she has told her supervisor about the roaches. During an interview with Dietary Aid (DA 1) on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE September 4, 2018, at 5:00 p.m., DA 1 stated that he has seen roaches coming out of the floor drain next to the food preparation sink area. DA 1 stated we know about the roaches. In a telephone interview with the pest control technician (PCT) on September 4, 2018, at 5:15 p.m., the PCT stated he is on a twice a month schedule with the facility. He stated he used to see a lot more roaches in the kitchen but not as much now compared to last year. He uses a product called Gel Maxforce and stated that this pest control product is used for routine maintenance. He further stated facility has not called him for issues with roaches. He also stated he has seen the foam sealant and plywood that covers the cracks and holes under the sink and that might be a harborage for roaches. (PCT) verified that he received a call from facility this morning and he will come in later to treat the kitchen to exterminate the pests and he will use a liquid product strong for roach infestation. During an interview with the maintenance supervisor (MS) on September 4, 2018, at 5:45 p.m., the MS stated staff verbally communicates with him regarding repairs or other issues. MS stated that lately the kitchen staff have not told him about roaches. A review of 2017 U.S. Food and Drug Administration Food Code, Insects and other pests are capable of transmitting disease to humans by contaminating food and foodcontact surfaces. Effective measures must be taken to eliminate their presence in food establishments. In addition routinely inspecting the premises for evidence of pests and if pests are found using methods to control and eliminate harborage conditions. In addition, according to the 2017 U.S. Food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and Drug Administration Food Code, Fixed equipment is installed in a way that ensures that equipment that is subject to moisture is sealed, prevents the harborage of insects and rodents and provides accessibility for monitoring of pests. A review of website (www.orkin.com) indicated cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks and stoves, as well as under floor drains and inside of motors and major appliances. In addition, the pest cockroaches can be carriers of various diseases because they are commonly found near waste deposits or in the kitchen, where food is present. Cockroaches often taint food with E. coli and Salmonella bacteria; also, exposure to cockroach waste and dead roaches over time can trigger allergies and asthma. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I83W11 Facility ID: CA920000055 If continuation sheet 8 of 8