Inspection Reports for
GlenBrook Health Center
1950 Calle Barcelona, Carlsbad, CA 92009, United States, CA, 92009
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
64% occupied
Based on a February 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 61
Capacity: 95
Deficiencies: 0
Date: Feb 9, 2026
Visit Reason
An unannounced case management visit was conducted following a self-reported unusual incident involving a resident who reported inappropriate behavior by an unknown male staff person.
Complaint Details
The visit was triggered by a complaint involving a resident reporting that an unknown male staff member wanted to purchase them and touched them inappropriately. The complaint is under investigation with possible follow-up visits or calls anticipated.
Findings
The Licensing Program Analyst conducted interviews and reviewed resident records related to the incident. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kahina Hadibi | Assisted Living Director | Met with during the inspection and informed about the incident and possible follow-up. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 95
Deficiencies: 0
Date: Feb 9, 2026
Visit Reason
An unannounced case management visit was conducted following a self-reported unusual incident involving a resident who reported inappropriate behavior by an unknown male staff person.
Complaint Details
The visit was triggered by a complaint involving a resident reporting that an unknown male staff member wanted to purchase them and touched them inappropriately. The complaint was self-reported by the facility and documented in an Unusual Incident/Injury Report and SOC 341 form.
Findings
The Licensing Program Analyst conducted interviews and reviewed resident records during the visit. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kahina Hadibi | Assisted Living Director | Met with during the inspection and involved in the incident discussion. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Annual Inspection
Census: 67
Capacity: 95
Deficiencies: 0
Date: Jan 15, 2026
Visit Reason
Licensing Program Analyst Nacole Patterson conducted an unannounced Required Annual Inspection to evaluate compliance with licensing requirements at Glenbrook Assisted Living Facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order. Confidential records were properly stored and licensing postings were observed.
Report Facts
Capacity: 95
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Executive Director | Met with Licensing Program Analyst during inspection |
| Kahina Hadibi | Assisted Living Director | Met with Licensing Program Analyst during inspection |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Sabel Martinez | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication use, discharge notifications, and safety measures in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents knew the location of survey results, improper use of psychotropic medications without prior non-pharmacological interventions, failure to notify the Long-Term Care Ombudsman before resident discharges, and inadequate supervision and assistive devices to prevent accidents.
Deficiencies (4)
Failure to ensure residents knew the location of the survey results binder.
Failure to prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function without prior non-pharmacological interventions.
Failure to notify the Office of the Long-Term Care Ombudsman before discharge for two sampled residents.
Failure to properly identify and provide necessary assistive devices for repositioning, leading to potential accident and injury.
Report Facts
Residents sampled: 4
Residents affected: 3
Residents sampled: 5
Residents affected: 2
Residents sampled: 4
Residents affected: 2
Residents sampled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of non-pharmacological interventions before antipsychotic medication and failure to address resident safety needs |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Confirmed no documented behaviors prior to antipsychotic medication for Resident 31 |
| Licensed Vocational Nurse 4 | Licensed Vocational Nurse | Confirmed Resident 27 did not have assistive device for positioning |
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Reported assisting Resident 27 with repositioning and noted unsafe use of bedside drawer |
| Social Services Director | Social Services Director | Stated Medical Records held responsibility for notifying Ombudsman of discharges and was unaware of timing requirements |
| Medical Records Director | Medical Records Director | Confirmed no written notification sent to Ombudsman and reviewed facility policy on discharge notices |
Inspection Report
Annual Inspection
Census: 70
Capacity: 95
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for Glenbrook Assisted Living Facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and documentation were present and in order.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Executive Director | Met during inspection and named in relation to facility condition and compliance |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Snezana Skrbic | Wellness Coordinator | Participated in facility tour and inspection |
| David Sharp | Operations Manager | Participated in facility tour and inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
An unscheduled visit was made to the facility on 9/20/24 in response to a report of Resident 1 falling and fracturing her left wrist.
Complaint Details
The investigation was triggered by a complaint regarding Resident 1's fall and wrist fracture. The complaint was substantiated by interviews and record reviews showing inconsistent implementation of the care plan.
Findings
The facility failed to ensure Resident 1's written care plan for transfers was consistently implemented, resulting in an unwitnessed fall while transferring into a chair. Interviews and record reviews indicated Resident 1 required assistance for safe transfers and walking, but staff did not consistently provide the needed supervision and reminders.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Report Facts
Prior falls: 2
Therapy notes dates: Therapy notes reviewed dated 9/1/24 through 9/5/24 and 9/8/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | CNA | Interviewed regarding Resident 1's mobility and care plan usage. |
| Certified Nursing Assistant 3 | CNA | Interviewed regarding Resident 1's walking and transfer supervision. |
| Director of Therapy | DPT | Interviewed and provided information on Resident 1's therapy and assistance needs. |
Inspection Report
Census: 72
Capacity: 95
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
The visit was an unannounced Case Management visit in response to a self-reported incident where a resident left the facility unassisted.
Findings
The resident was located and assisted back into the facility within 7 minutes with no injuries. No health or safety issues were identified and no deficiencies were cited or observed during the visit.
Report Facts
Time resident was missing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 95
Capacity: 95
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
An unannounced required one-year inspection was conducted to evaluate compliance with licensing regulations at Glenbrook Assisted Living Facility.
Findings
The inspection found the facility to be in full compliance with no deficiencies cited. The facility was clean, well-maintained, and residents were treated with dignity. Safety systems were operational and staff records were complete.
Report Facts
Hospice care waiver approved residents: 7
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sadie Harness | Administrator | Facility administrator who granted entry and participated in the inspection |
| Kahina Hadibi | Assistant Living Director | Accompanied the Licensing Program Analyst during the facility tour |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 95
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging neglect/lack of supervision resulting in resident injury at Glenbrook Assisted Living Facility.
Complaint Details
The complaint alleged neglect/lack of supervision resulted in injury to Resident 1, who had a large bruise on the left arm. The allegation was unsubstantiated after interviews with staff, residents, and an outside medical provider could not verify the cause of the injury.
Findings
The investigation found no preponderance of evidence to prove the alleged neglect or lack of supervision causing injury. Interviews and record reviews did not corroborate the allegation, resulting in an unsubstantiated finding.
Report Facts
Facility capacity: 95
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Analyst during complaint investigation and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services and medication administration policies, specifically reviewing medication administration for Resident 361.
Findings
The facility failed to ensure that Resident 361 received chewable Aspirin as ordered by the physician, as the nurse did not instruct the resident to chew the medication before swallowing, potentially causing decreased drug action or unexpected side effects.
Deficiencies (1)
Failure to ensure Resident 361 received medication according to physician's orders; chewable Aspirin was swallowed whole without instructions to chew.
Report Facts
Residents reviewed for medication administration: 8
Medication dosage: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 2 | Licensed Nurse | Administered Aspirin to Resident 361 without proper instructions |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration failure |
Inspection Report
Routine
Census: 57
Deficiencies: 5
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality and safety in nursing care, nutrition, medication administration, food services, infection control, and pest control at the Glenbrook nursing facility.
Findings
The facility was found deficient in multiple areas including failure to respond appropriately to low blood glucose readings, delayed nutritional assessments for residents with pressure injuries and severe weight loss, improper medication administration, inadequate food safety and sanitation practices in the kitchen, poor pest control, and failure to ensure proper infection control precautions for visitors.
Deficiencies (5)
Licensed nurses did not respond to Resident 3's low blood glucose readings by assessing for hypoglycemia and notifying the physician.
Nutritional assessment was not conducted timely for residents with pressure injuries and severe weight loss (Resident 23).
Resident 361 received chewable Aspirin without proper instructions to chew, contrary to physician's order.
Food and Nutrition Services failed to maintain food safety, sanitation, and pest control standards in the kitchen, including unclean floors, unlabeled foods, fruit flies, and improper food preparation.
Resident 8's visitor did not wear proper personal protective equipment while in contact with the resident on isolation precautions.
Report Facts
Blood glucose readings below 70 mg/dl: 4
Weight loss percentage: 16.43
Facility census: 57
Number of residents affected by deficiencies: 15
Number of residents affected by weight loss deficiency: 1
Number of residents affected by medication administration deficiency: 1
Number of residents affected by infection control deficiency: 1
Number of flies observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Named in medication and blood glucose assessment deficiency findings. |
| Director of Nursing | DON | Provided statements regarding nursing standards and deficiencies. |
| Registered Dietitian | RD | Involved in nutritional assessment deficiencies and kitchen food safety. |
| LN 2 | Licensed Nurse | Observed administering medication incorrectly to Resident 361. |
| Certified Nurse Assistant | CNA 4 | Observed visitor not wearing PPE in Resident 8's room. |
| Director of Food and Nutrition Services | DFS | Acknowledged kitchen sanitation and pest control deficiencies. |
| Executive Chef | EXC | Acknowledged kitchen sanitation and pest control deficiencies. |
| Lead Cook | LCK | Observed preparing tuna salad incorrectly and kitchen sanitation issues. |
| Dishwasher | DW 1 | Did not timely log dishwashing temperatures. |
| Dishwasher | DW 2 | Did not timely log dishwashing temperatures. |
| Infection Preventionist | IP 1 | Provided statements regarding infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement a care plan for bladder scanning and straight catheterization for Resident 1 as ordered by the physician.
Complaint Details
The complaint investigation found that Resident 1 was not bladder scanned every 8 hours as ordered, and straight catheterization was not performed appropriately. The resident developed urinary tract infection, sepsis, and acute renal failure due to these failures. The physician confirmed the order was not PRN but required every 8 hours. Licensed nurses lacked training and did not follow procedures, contributing to the adverse outcomes.
Findings
The facility failed to follow physician orders for bladder scanning every 8 hours and straight catheterization if bladder volume exceeded 400 cc. Licensed nurses did not follow catheterization procedures, removing more than the recommended 800 cc of urine at one time, and lacked education on bladder scanning and catheterization. As a result, Resident 1 developed urinary tract infection, sepsis, and urinary retention requiring hospital transfer and IV antibiotics.
Deficiencies (3)
Failure to develop and implement a care plan for bladder scanning and straight catheterization as ordered by the physician.
Licensed nurses did not follow straight catheterization procedure, removing over 1400 cc of urine instead of the recommended maximum of 800 cc.
Facility did not educate nurses on bladder scanning and straight catheterization prior to June 2021.
Report Facts
Urine volume removed during catheterization: 1400
Urine volume threshold for catheterization: 400
Bladder scan frequency: 8
Number of bladder scans recorded: 2
Date of hospital admission: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Did not follow straight catheterization procedure, removed over 1400 cc urine |
| Director of Nursing | Director of Nursing | Stated nurses did not follow physician's order and emphasized importance of bladder scanning every 8 hours |
| Physician 1 | Physician | Ordered bladder scanning every 8 hours and catheterization if over 400 cc; confirmed order was not PRN |
| Director of Staff Development | Director of Staff Development | Stated importance of nurse education on bladder scanning and catheterization to prevent complications |
| LN 3 | Licensed Nurse | Reported no formal training on bladder scanner or catheterization; would catheterize up to 1500 cc if ordered |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 95
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a resident who went AWOL from the facility without staff witnessing. The purpose was to investigate the incident and verify resident safety.
Complaint Details
The complaint involved a resident who went AWOL early morning on 04/24/2023. The resident was returned safely by police. The investigation found no evidence of failure in assessment or observation by staff.
Findings
The resident was found unharmed and wearing a 'wander guard' device after the incident. The facility had appropriate safety measures including proximity sensors and staff observation protocols. No deficiency was cited during the visit.
Report Facts
Incident date: Apr 24, 2023
Incident report submission date: Apr 25, 2023
Resident assessments: 3
Staff check interval: 2
Facility capacity: 95
Resident census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Executive Director | Met during visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 60
Capacity: 95
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
Licensing Program Analyst Tammer de los Santos visited the facility to conduct an annual required licensing inspection.
Findings
The inspection verified compliance with infection control practices including universal entry screening, visitor sign-in policy, hand hygiene promotion, face coverings worn by staff, and availability of hand sanitizer and visitation area. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kahina Hadibi | Director | Facility Director who granted entry and participated in exit interview. |
| Tammer de los Santos | Licensing Program Analyst | Conducted the annual required licensing inspection. |
Inspection Report
Census: 74
Capacity: 95
Deficiencies: 0
Date: May 13, 2022
Visit Reason
An unannounced case management visit was conducted following the facility's report of a resident death on May 11, 2022.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst toured the facility, conducted staff interviews, and reviewed records.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Vicky Williamson | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Simon Jacob | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 95
Deficiencies: 0
Date: May 3, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that facility staff were accepting tips from residents.
Complaint Details
The complaint alleged that staff were accepting tips from residents. The investigation included interviews and record reviews and concluded the allegation was unsubstantiated.
Findings
The investigation found no evidence that staff were accepting tips from residents. The facility enforces a no tipping policy and participates in a voluntary, anonymous Resident Gift Fund sponsored by the Resident Council, which does not involve staff in collection. The allegation was unsubstantiated.
Report Facts
Facility capacity: 95
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Ryan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sadie Harness | Administrator | Facility administrator involved in investigation and receipt of report |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 70
Capacity: 95
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
An unannounced case management virtual visit was conducted due to the COVID-19 pandemic following a self-reported incident involving a resident who was hospitalized with an injury and subsequently passed away.
Findings
No deficiencies were cited during the visit after reviewing facility records and interviewing staff.
Report Facts
Capacity: 95
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Kristina Ryan | Licensing Program Analyst | Conducted the unannounced case management virtual visit |
| Simon Jacob | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 70
Capacity: 95
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
The visit was an unannounced Case Management Visit conducted in response to the death of Resident 1 (R1).
Findings
No immediate health or safety issues were observed during the tour of the facility. No deficiencies were cited or observed at the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Manager during the visit and participated in the exit interview. |
| Josie Ledesma | Director of Nursing | Conducted facility tour with Licensing Program Manager. |
| Rebecca Hedgecock | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Icela Estrada | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 70
Capacity: 95
Deficiencies: 0
Date: Apr 2, 2021
Visit Reason
An unannounced case management visit was conducted to provide technical assistance and review the facility's COVID-19 mitigation plan via a virtual FaceTime visit due to COVID-19 restrictions.
Findings
During the visit, the Licensing Program Analyst toured the facility and interviewed the Administrator. No deficiencies were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Administrator | Met with Licensing Program Analyst during the visit |
| Kristina Ryan | Licensing Program Analyst | Conducted the unannounced case management visit |
| Simon Jacob | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 95
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The visit was an unannounced Case Management visit due to an incident report received at the San Diego Regional Office on March 3, 2021.
Complaint Details
Visit triggered by an incident report received on March 3, 2021. No deficiencies were cited during this visit.
Findings
During the visit, a brief tour of the facility, a health and safety check of the residents, and record review were conducted. No deficiencies were cited during the visit, but further investigation is necessary and future visits may be required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Harness | Executive Director | Met during the visit and participated in the exit interview. |
| Alexandre Vo | Licensing Program Manager | Conducted the unannounced Case Management visit. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Routine
Census: 84
Deficiencies: 11
Date: Jan 16, 2020
Visit Reason
The inspection was conducted based on routine food and nutrition services observations, staff interviews, and record reviews to assess compliance with food safety, dietary operations, and infection control standards.
Findings
The facility failed to ensure effective oversight and safe practices in the Food and Nutrition Services department, including storage of unlabeled and expired foods, serving unpasteurized eggs, improper food preparation and menu compliance, inadequate staff competence, use of unsafe cleaning chemicals, and failure to follow infection control protocols. These deficiencies placed residents at risk of foodborne illness and compromised nutritional care.
Deficiencies (11)
Failure to ensure effective oversight of dietary operations and food safety practices, including storage of unlabeled, undated, and expired foods.
Serving unpasteurized eggs to residents, contrary to food safety regulations.
Improper storage of wet pans and dirty dishes, including stacking wet pans and storing dirty scoops with clean ones.
Kitchen staff demonstrated poor competence in food safety, including incorrect thermometer calibration and lack of cool down logs for ambient temperature foods.
Failure to follow therapeutic menu and recipe compliance, resulting in residents receiving incorrect portion sizes and improperly prepared foods.
Failure to ensure food texture compliance for residents on mechanical soft diets, serving whole meatloaf slices instead of chopped pieces.
Failure to procure, store, prepare, and serve food in accordance with professional standards, including use of unpasteurized eggs, unlabeled and expired foods, and unsafe cleaning chemicals.
Failure to wear appropriate hair and beard nets by kitchen staff and visitors.
Failure to follow policy regarding use and storage of foods brought to residents by family and visitors, including lack of labeling and dating of outside food.
Failure to properly cover garbage receptacles with lids when transporting trash to the dumpster, risking pest infestation and disease spread.
Failure to implement proper infection prevention and control practices during gastrostomy tube dressing change, including failure to perform hand hygiene between glove changes.
Report Facts
Residents affected: 84
Expired nutritive drinks: 3
Wet stainless steel pans stacked: 15
Dirty serving scoops: 5
Poached eggs observed: 11
Meatloaf portion size: 1.75
Thermometer calibration temperature: 32
Thermometer observed calibration readings: 41.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 11 | Licensed Nurse | Failed to perform hand hygiene between glove changes during gastrostomy tube dressing change |
| CKS | Cook Supervisor | Responsible for food ordering and kitchen oversight; involved in ordering unpasteurized eggs and food safety practices |
| FSDRD | Facility Staff Registered Dietitian | Provided interviews regarding dietary operations, food safety, and oversight; unaware of some unsafe practices |
| DA 1 | Dietary Aide | Interviewed regarding improper storage of wet pans and dirty scoops |
| CK 1 | Cook | Observed preparing food and involved in food portioning and hair net noncompliance |
| CK 2 | Cook | Observed pureeing food and unaware of cool down logs |
| CK 3 | Cook | Interviewed about thermometer calibration and recipe compliance |
| CK 4 | Cook | Interviewed about food preparation and cool down process |
| DW 1 | Dietary Worker | Observed transporting garbage without lid covering |
| MDR | Maintenance Director | Interviewed about ice machine cleaning and black smudge |
| MW 1 | Maintenance Worker | Interviewed about ice machine cleaning practices |
| ADM | Administrator | Interviewed regarding dietary and food safety oversight |
| DON | Director of Nursing | Interviewed about infection control and thermometer calibration |
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