F0921

E

Failure to Maintain Functional Kitchen Elevator Resulting in Unsafe Food Handling and Staff Strain

Monterey Park, California Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Facility staff and leadership failed to maintain a safe and functional environment by allowing the kitchen elevator, which connects the basement kitchen to the main floor, to remain inoperable for an extended period. The Assistant Administrator and Maintenance Supervisor reported that the elevator had been broken since the last quarter of 2024, with documented elevator company recommendations for maintenance and replacement that were not completed after early September 2024. The Administrator stated the elevator ultimately was deemed not repairable and needed replacement, and that the facility notified the state construction authority about the replacement project but did not notify the district office about the existing inoperable elevator.

Because the elevator was not functioning, the facility relocated food distribution and tray set-up to an upstairs conference room and required dietary staff to transport all food, beverages, and supplies via the stairwell. Surveyors observed the conference room being used as a food distribution and serving area, containing a steam table, plate warmer, refrigerator, meal carts, and a fan. Dietary staff were seen repeatedly carrying trays of beverages and large pans of food up and down the stairs from the basement kitchen, with one dietary aide observed making multiple trips, breathing heavily, and sweating. The Dietary Supervisor confirmed that since the elevator failure, staff had been using the stairwell for food delivery and vendor deliveries, and reported that one staff member had been injured during this period and that the facility had not provided in-services on safe food delivery or fall prevention related to this change in process.

Surveyors also identified failures in maintaining proper food temperatures and timely refrigerated storage under these altered conditions. During lunch service in the conference room, cold beverages such as apple juice and milk were measured at 46.9°F and 52.5°F, respectively, while the Dietary Supervisor acknowledged the room was warm during service, there was no ice available in the conference room, and that cold foods should be held at 41°F or below. In the basement, staff and the Dietary Supervisor described that food and supplies were now left by vendors in the parking lot and then carried down the stairs by kitchen staff, with one dietary aide stating it could take about two hours to bring supplies when working alone and acknowledging that dairy products left outside for a long time could spoil. These practices conflicted with the facility’s own food safety and storage policies and the FDA Food Code requirements for hot and cold holding and immediate refrigeration upon receipt.