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F0801
F

Failure to Employ Qualified Food and Nutrition Services Director and Provide Sufficient Dietitian Oversight

Simi Valley, California Survey Completed on 08-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a full-time Director of Food and Nutrition Services (DFN) who met both federal and state educational qualification requirements. The individual who had been serving as the Dietary Manager (DM) for the past year had not taken the Certified Dietary Manager (CDM) exam and was therefore unqualified for the position. This was confirmed by multiple staff interviews, including the per diem Dietary Services Supervisor (PD-DSS) and the Administrator, who both acknowledged that the DM did not meet the necessary qualifications. The DM resigned on the day of the survey, leaving the facility without a qualified DFN. Additionally, the facility relied on a part-time contracted Registered Dietitian (RD) who did not provide sufficient, regularly scheduled consultation to the DFN. The RD last completed oversight of the foodservice operations in February, several months prior to the survey, and did not follow up to ensure that identified deficits were addressed. Documentation showed that issues such as missing menu printouts, expired food handler certifications, and lack of a substitution log were not resolved. The RD confirmed that she had not provided adequate oversight or consultation to the DM during this period. Interviews with dietary aides and review of facility policies further revealed that no other staff members met the qualifications to serve as DFN or had completed the necessary training programs. The facility's own policies and job descriptions require a qualified DFN and regular consultation from an RD if the DFN is not a dietitian. The lack of qualified leadership and insufficient RD oversight had the potential to affect all residents receiving meals from the kitchen.

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