Health inspection·November 26, 2025

F921 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. §72637. General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. On 10/17/2020, an unannounced visit was conducted by the California Department of Public Health (CDPH) to investigate a complaint regarding a leaking pipe in a resident’s room and in the kitchen for about 1 week. The facility failed to ensure that the facility followed proper food handling practices in accordance with the professional standards for food service safety (the rules, regulations, and guidelines that ensure food is handled, prepared, and stored to prevent foodborne illnesses [also known as food poisoning, it is a condition that occurs when consuming contaminated food or beverages]) such as prevention of cross-contamination, maintaining equipment and surfaces in clean, sanitary condition, by failing to: 1. Ensure the facility did not prepare the residents’ meals in the facility’s kitchen with a large gaping hole that measured three (3) feet (ft.- unit of measurement) by four (4) ft. from the kitchen ceiling exposing, dry wall, pipes, wood framings, and a bent steel panel for light fixture hanging over the food tray transport rack with food trays ready to be served to the 50 residents who are receiving food prepared in the facility’s kitchen, resulting from a water leak and with persistent water leak in other sections of the kitchen ceiling on 10/18/2025 in the morning. 2. Create and implement a kitchen emergency plan that includes the facility’s plan if kitchen is under construction and/or is deemed not safe to be used to prepare the residents’ meals. This deficient practice had the potential for the 50 residents to experience foodborne illness from ingesting food contaminants from debris, dust, or water from the ceiling that can fall into food, cooking equipment, or on preparation surfaces in the kitchen which can lead to serious sickness and/ or death. During an interview on 10/17/2025, at 6 PM, with Assistant Director of Nursing (ADON), ADON confirmed that the facility’s kitchen’s ceiling had a leak and believed it started two (2) days ago around 10/15/2025. The ADON stated the facility’s kitchen was still being utilized for food preparation for the residents. During an interview on 10/17/2025, at 6:31 PM, with Maintenance Supervisor (MS), MS stated the leak on the kitchen ceiling started on Friday 10/10/2025. MS stated a part of the kitchen’s ceiling and drywall was removed by the plumbers but did not know when exactly it was removed. During an observation on 10/18/2025 at 7AM, in the facility’s kitchen, there was a large gaping hole in the kitchen ceiling with exposed pipes, hanging drywall, wood framings, and a bent steel panel for light fixture hanging over the hand washing sink, food tray transport rack and approximately five feet away from the stove and food preparation area were observed.  On the opposite side of the kitchen, there were two metal pans, and multiple wet towels on the floor that were visibly wet and catching the leak from the ceiling. During an observation on 10/18/2025, at 7:08 AM, the Kitchen staff had already prepared the residents’ breakfast, and the residents’ food was on the food trays and placed in the food tray transport rack and was being taken up to resident’s rooms. The Kitchen staff were observed pushing the food tray transport rack and walking under the large gaping hole in the kitchen ceiling with exposed pipes, hanging drywall, wood framings, and a bent steel panel for light fixture to leave the kitchen.  Observed there was a red plastic food tray connected to a portion of the large gaping hole in the kitchen ceiling and hanging above the handwashing catching a small leak and dripping into a gray trash bin.  On the opposite side of the kitchen, there was a second leak that was dripping in a yellow trash bin.  During an interview on 10/18/2025, at 7:15 AM, with ADMN, ADMN stated the water leak found in the facility kitchen ceiling was first noticed on 10/10/2025.  ADMN stated, Plumber Company staff 1 (PC1) came to the facility on 10/11/2025 to repair leaks in kitchen, and it was PC 1 who opened the kitchen ceiling to determine the cause of the leak.  ADMN stated PC1 does not repair drywall, so he had to get another company (PC2) to fix the ceiling.  During an interview on 10/18/2025, at 7:45 AM, with ADMN, ADMN confirmed the facility continued to use their kitchen for resident food preparation including the residents’ breakfast on 10/18/2025. ADMN stated the facility has 50 residents who are receiving their food prepared in the facility kitchen out of their 51 residents. ADMN stated he asked the plumber (did not specify if PC1 or PC2) if it was still safe to use the kitchen and the plumber told the ADMN yes. ADMN stated, ADMN did not consult any outside company or the facility’s Dietary Supervisor (DS) to confirm if it was safe to use the facility’s kitchen to prepare the residents’ food and felt that expertise of plumbers was enough. During an interview on 10/18/2025, at 7:54 AM with PC1, PC 1 stated they came out on 10/11/2025, discovered a leak in the facility’s kitchen ceiling, and they opened the ceiling to expose the leaking pipe which created the large gaping hole over the hand washing sink. PC 1 stated PC 1 repaired the leak and placed a plastic tarpaulin (plastic tarp) over the large gaping hole. PC1 stated that it was safe to prepare the residents’ food with the plastic tarp covering the large gaping hole on the kitchen’s ceiling but does not know if it is safe to prepare the residents’ food if the large gaping hole is not covered. During an interview on 10/18/2025, at 8:04 AM, with ADMN, ADMN stated, PC2 came on the morning of 10/17/2025 and removed the plastic tarp from the kitchen’s ceiling. ADMN confirmed food preparations in the facility’s kitchen continued after the plastic tarp was removed by PC2 on 10/17/2025. PC2 also stated, the large gaping hole in the facility’s kitchen above the handwashing sink measured 3 ft. by 4 ft. During an interview on 10/18/2025, at 8:10 AM, with PC2, PC2 stated, they came to the facility on 10/17/2025 around 10 AM and PC2 removed the plastic tarp covering the large gaping hole from the kitchen’s ceiling. During an interview on 10/18/2025, at 8:22 AM, with Cook 1, Cook 1 stated that food preparation continued in the facility’s kitchen even though there was a large gaping hole in the kitchen’s ceiling. Cook 1 stated that food was not prepared while the plumbers were working, but sometimes the tarp was on and sometimes it was off while the plumbers worked.  Cook 1 confirmed, today 10/18/2025, the residents’ breakfast was prepared with no plastic tarp covering the ceiling. During an interview on 10/18/2025, at 9:52am, with Dietary Supervisor (DS), DS stated they were informed by PC1 on 10/11/2025 that the kitchen was safe to use while there is a plastic tarp covering the large gaping hole in the kitchen’s ceiling.  DS stated if there is no plastic covering large gaping hole in the kitchen’s ceiling, then the kitchen should not be used for residents’ meal preparation.  DS stated they should be preparing food in the kitchen of their sister facility across the street to ensure patient food safety.  DS states that there is potential for something to drop from the open ceiling into the food which could potentially harm the patients. During an interview on 10/18/2025, at 2:54 AM, with ADMN, ADMN stated the facility did not have a policy or a kitchen emergency plan that includes the facility’s plan if kitchen is under construction and/or is deemed not safe to be used to prepare the residents’ meals. The only policy the facility have is the "Dietary Considerations for Residents: Disaster Emergency Preparedness”. A review of the Facility's policy titled, "Dietary Considerations for Residents: Disaster Emergency Preparedness”, dated 1/20/2025, indicated that emergency dietary planning for residents and staff includes the consideration of such situations as evacuation and long-term sheltering in place without the support of outside resources food, water and food service supplies or utilization of sister facility’s kitchen if available.  The above violation had a direct or immediate relationship to the health, safety, or security of the residents residing in the facility.