Health inspection·March 27, 2026

Code of Federal Regulations, Title 42, Section §483.60(i) Food safety requirements. The facility must – (§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. California Code of Regulations, Title 22, Section §72333. Dietetic Service -General. “Dietetic service” means a service organized, staffed and equipped to assure that food service to patients is safe, appetizing and provides for their nutritional needs. California Code of Regulations, Title 22, Section 72523 – Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 2/9/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility for an annual health recertification survey. The facility failed to: 1. Implement its policy and procedure (P&P) titled “Food Preparation and Service,” dated 11/5/2025. 2. Ensure safe and sanitary food storage and preparation practices in the kitchen for 79 residents when on 2/9/2026. Cook 1 thawed fish in the preparation sink without monitoring and adhering to required time and temperature guidelines for thawing, in accordance with Federal and Retail Food Code (2022) which requires that time and temperature control for safety (TCS – food items requiring strict temperature controls) foods that are slacked (the process of raising the temperature of frozen TCS foods to make it easier to cook evenly) may be held at any temperature only if the food remains frozen. Food must be completely submerged under running water during thawing, and the process does not allow thawed portions of raw animal food requiring cooking to exceed 41 degrees Fahrenheit (°F, a scale of temperature) for more than four (4) hours. This four-hour time frame includes: (a) the time the food is exposed to running water and the time required for preparation prior to cooking, (b) and the time it takes under refrigeration to reduce the food temperature under 41°F. As a result, 79 residents were placed at risk for foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs and harmful toxins [poisonous substances that cause diseases or damage when absorbed by the body] or chemicals) from fish served at the facility, which could lead to serious complications including dehydration (a condition occurring when the body loses more fluids primarily water, than it takes in, preventing normal, healthy functioning), malnutrition (a serious condition resulting from an imbalance in nutrient intake), and sepsis (a life-threatening medical emergency caused by the body’s extreme response to an infection) requiring hospitalization. On 2/9/2026 at 8:37 a.m., a pan of fish (unsealed) was observed thawing under slow running water in the meat preparation sink. During a follow-up observation on 2/9/2026 at 9:00 a.m., Cook 1 was observed removing the fish from the preparation sink and transferring it to a colander (a bowl-shaped kitchen utensil with small holes used for rinsing food or draining liquids from food items). During a concurrent interview and video review of the fish being thawed on the sink, on 2/9/2026 at 9:18 a.m., the Dietary Supervisor (DS) stated that the fish was not in sealed plastic while being thawed. The DS stated the facility’s process for thawing fish is to first place the fish in the refrigerator, then transfer it to a pan, defrost (to turn frozen food into a thawed, unfrozen state) it in the sink, followed by breading (coating fish in layers typically flour, egg and breadcrumbs to create a crispy, protective crust) the fish and cooking it. The DS stated that dietary staff (Cook 1) thaw fish in the preparation sink under running water, however, dietary staff (not specified) would not know the temperature of the water because they (dietary staff) do not check or record the water temperature. The DS stated that the temperature of the fish must be monitored to ensure it does not rise above or enter the unsafe temperature danger zone range ([41°F to 135°F], where bacteria multiply rapidly, doubling in as little as 20 minutes) within four (4) hours. The DS stated the food temperature should not exceed 45°F during thawing and stated that the cooks (not specified) should be monitoring food temperatures throughout the thawing process. During an interview on 2/9/2026 at 9:32 a.m., with Cook 1 and the DS, Cook 1 stated that on 2/9/2026, he (Cook 1) was responsible for thawing the fish in the preparation sink by placing the fish in a pan under cold flowing water. Cook 1 stated he did not take the temperature of the fish, but since it came from the freezer (an appliance, room or device designed to maintain temperatures at or below 0°F to preserve food), the temperature was at 0°F. Cook 1 stated he (Cook 1) removed the fish from the freezer and started thawing the fish around 6 a.m. Cook 1 stated he (Cook 1) discontinued thawing and removed the fish from the sink at around 9:00 a.m. Cook 1 further stated that he (Cook 1) did not check or record the temperature of the fish when he took it out from the sink. During a concurrent observation and interview on 2/9/2026 at 9:40 a.m., of the thawed fish, with the DS and Cook 1, Cook 1 stated the fish were inside the oven. Observed Cook 1 removed three (3) pans of fish from the oven. The DS and the surveyor obtained temperatures of five (5) randomly selected pieces of fish with the following results: • Fish 1: 64.9°F (within the temperature danger zone at the time of observation) • Fish 2: 64.9°F (within the temperature danger zone at the time of observation) • Fish 3: 63.9°F (within the temperature danger zone at the time of observation) • Fish 4: 65.1°F (within the temperature danger zone at the time of observation) • Fish 5: 69.6°F (within the temperature danger zone at the time of observation) During an interview on 2/9/2026 at 9:41 a.m., with the DS and Cook 1, Cook 1 stated he (Cook 1) was waiting for the pureed food to finish cooking, which is why he (Cook 1) did not cook the fish immediately after thawing. The DS stated that staff (not specified) did not measure the temperature of the fish during the thawing process. The DS further stated the fish could not be served to residents because the temperature exceeded 45°F. The DS stated he would contact the Registered Dietitian (RD) Consultant to obtain a substitute menu item. During an interview on 2/9/2026 at 11:37 a.m., the DS stated the facility does not have records or time and temperature logs for monitoring the thawing of foods, however, he (DS) would start a log moving forward. The DS stated the facility’s current process for temperature monitoring is to measure the final cooking temperature of food and to recheck the temperature prior to serving it in tray line (an area where foods were assembled from the steamtable to the resident’s trays). The DS stated they (dietary staff) do not measure the temperature of foods prior to the start of cooking. During an interview on 2/9/2026 at 12:07 p.m., Cook 2 stated their thawing process is to thaw food in the refrigerator for three (3) days, but sometimes they (dietary staff) thaw under running water. Cook 2 stated that he (Cook 2) usually thaws the thin fish in the sink for 20 to 40 minutes. Cook 2 stated he begins cooking the fish when it is not too frozen. Cook 2 stated that fish at 50°F or below, is okay and safe to cook, but fish at 51°F or above, is too thawed and not safe to cook. During a follow-up interview on 2/10/2026 at 9:50 a.m. with the DS and Cook 1, Cook 1 stated he did not cook the fish immediately after thawing yesterday (2/9/2026) because it was too early to cook it at 10 a.m., and he needed to wait until 11 a.m. to cook it. The DS then stated that delaying cooking the fish until 11 a.m. could allow the fish temperature to rise, making it unsafe to cook. The DS also stated that Cook 1 did not measure the temperature during the thawing process and would not measure the temperature of the fish at the start of cooking. The DS stated therefore Cook 1 would not know if the fish had entered the temperature danger zone before cooking. The DS stated that this could cause residents to get sick and develop foodborne illness such as salmonella poisoning (a common bacterial foodborne illness causing diarrhea [loose, watery stools], fever [high body temperature, usually above 100.4°F, signaling the body is fighting an infection or illness], and abdominal cramps [sudden, tight or aching sensations in the stomach muscles] within six hours to six days of exposure). During an interview on 2/10/2026 at 10:14 a.m., the RD stated that the facility’s thawing process involves pulling the food item such as fish or meat from the freezer three (3) days before use and placing it in the refrigerator. The RD also stated that fish or meat may be thawed under running water for as long as the flow is sufficient and food is cooked immediately afterward. The RD stated the process of thawing in the sink included: 1. Cold water must be continuously flowing. 2. Cook the food immediately and food must not be refrozen. 3. Thawing requires time and temperature monitoring. Staff have two (2) hours to complete thawing, and the food temperature should be at a chilled temperature (refers to holding, storing or serving cold TCS food at a temperature of 41°F and below) and refrigerated temperature of 41°F and below. 4. Staff do not log time and temperature during thawing due to the time limit, so the temperature of the food is not checked during the thawing process. The RD stated that staff (dietary/kitchen staff) were not required to complete a log because they have a two-hour time limit for thawing under the water. The RD stated the thawing process was too long yesterday (2/9/2026), and the fish temperature could rise further if it was not cooked immediately. The RD stated that the fish was not appropriate to cook because the extended thawing and preparation time compromised its safety. The RD stated that monitoring time and temperature is essential for food safety and that food should be cooked to its required internal temperature. However, if food is already compromised due to improper time and temperature before cooking and is then consumed by the residents, they (residents) could potentially become ill from foodborne illnesses. The RD also stated that there may have been a misunderstanding regarding staff not needing to fully thaw food before cooking and stated that additional in-service (short teaching sessions designed to update staff on best practices, safety protocols, and regulatory requirements) training on proper thawing procedures is needed. During a concurrent interview and record review on 2/10/2026 at 12:36 p.m., with the DS and RD, the facility’s P&P titled “Policy: Thawing of Meats,” dated 11/5/2025 was reviewed. The P&P indicated “(3) Submerge under running, potable water (water that is safe for consumption, bathing and cleaning) at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41°F to 140°F) for more than four hours, which includes the time the food was thawed. Use immediately.” The RD stated that staff have two hours for thawing and four hours total for food thawing and food preparation. The RD stated that the temperature of the fish must be checked because staff (dietary/kitchen staff) would not know when the fish temperature rises during the thawing process, particularly in the thin portion of the fish. The RD stated that the policy requires both time and temperature control, however, staff (dietary/kitchen staff) were only using time control and therefore did not complete a log. The RD stated that monitoring temperature is necessary to ensure the fish remains below 41°F and is safe to cook, to prevent foodborne illnesses. During a concurrent interview and record review on 2/10/2026 at 3:16 p.m., with the DS and RD, the in-services log for thawing of food, dated 4/3/2023, 9/26/2023, 10/25/2023, 4/3/2024, 5/15/2024, 8/20/2024 and 1/12/2026 were reviewed. The DS stated that he provided in-service training to staff regarding thawing of meats by pulling them from the freezer to the refrigerator according to the pull schedule. The DS stated he (DS) could only locate lesson plans and sign in sheets for in-services on 1/12/2026, 5/15/2024 and 10/25/2023 related to meat thawing. The DS stated he only provided an in-service to the staff regarding thawing in the refrigerator by pulling the meat or fish from the freezer to the refrigerator three (3) days before use and using a meat thawing label and tracker. The DS stated that he (DS) did not provide in-service training on thawing in the sink. The RD stated that while each in-service includes discussion of different thawing processes, they were unable to provide lesson plans or documentation to verify this. During a concurrent interview and record review on 2/11/2026 at 4:48 a.m., with the DS, the Competency Test for Cook 1 dated 6/2023 was reviewed. The competency test indicated Cook 1 received a score of zero (0) on his Competency Test. The DS stated Cook 1 received a score of zero in the in-service test and that he (DS) did not review the test and the incorrect answers with the employee (Cook 1). The DS further stated that the score should have been totaled to verify Cook 1’s competency, and he (DS) failed to document the score to determine whether Cook 1 was competent on the day the test was given. The DS stated he (DS) has no other records for Cook 1. A review of the facility’s P&P titled “Food Preparation and Service,” dated 11/5/2025, the P&P indicated, “Food and Nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy interpretation and implementation: 1. Danger zone means temperatures above 41°F and below 135°F that allow the rapid growth of pathogenic microorganisms (or pathogens, tiny organisms that can make you sick if they get inside your body) that can cause foodborne illness. Potentially Hazardous Foods (PHF – also known as TCS foods, are items that require strict temperature management to prevent rapid growth of infectious bacteria or toxin production) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause foodborne illness outbreak if consumed. 2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time and temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Example of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized (food or beverages that have not been heated to kill pathogens, bacteria, and germs, leaving them in their raw, natural state) eggs, milk, yogurt and cottage cheese….” The P&P further indicated “Food Preparation, Cooking, and Holding time/Temperatures (1) The “danger zone” for food temperatures is above 41°F and below 135°F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) The longer foods remain in the “danger zone” the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained or below 41°F or at or above 135°F. (4) Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness.” The facility failed to: 1. Implement its P&P titled “Food Preparation and Service,” dated 11/5/2025. 2. Ensure safe and sanitary food storage and preparation practices in the kitchen for 79 residents when on 2/9/2026. Cook 1 thawed fish in the preparation sink without monitoring and adhering to required time and temperature guidelines for thawing, in accordance with Federal and Retail