Failure to Address Kitchen Code Violations in QAPI Led to Food Service Interruption
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not addressing code compliance corrective actions related to the physical environment of dietetic services, as required by the County Department of Health Services (CDHS). Despite receiving a Site Review Inspection Report from CDHS indicating that the kitchen's grease trap was in disrepair and not in compliance with the California Retail Food Code, the facility did not take action to repair the issue. The report was received by the previous Administrator, the Dietary Manager, and the Maintenance Manager, but was not discussed in QAPI meetings or addressed in any QAPI documentation. The previous Administrator did not communicate the findings or initiate repairs, and the issue was not handed over to the interim Administrator. As a result of the facility's inaction, wastewater overflowed onto the kitchen floor from the grease trap, leading to a CDHS inspection and the immediate suspension of the facility's Retail Food Permit. This action required the facility to cease all food production operations, interrupting food services for 57 out of 59 residents who relied on the facility's kitchen. Review of facility policy confirmed that the QAPI committee is responsible for addressing such issues, but there was no evidence that the CDHS inspection report or required kitchen repairs were ever incorporated into the QAPI process.