Inspection Details: KIT012040


Date
5/19/2026
Event ID
KIT012040
Inspection type(s)
Kitchen
Deficiencies cited
2

Citation Details

C0240
Severity Level: 2
Visits: 2
Scope
L2 Widespread
Visit Number
1
Visit Date
5/19/2026
Corrected Date
N/A
Details

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/19/26 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Stainless steel wall behind cooking equipment – drips of grease; * Exterior area of hood over cooking equipment – greasy, handprints; * Side of steamer – food splatters; * Sides of grill and deep fat fryer – drips of grease * Front of deep fryer and refrigerator on cooking line – smears/drips; and * Wall underneath spray hose sink in dishwashing area – significant build up of black matter. Other areas of concern included: * Cutting board on service line – scored and stained and * Slicer not covered when not in use. Improper food storage included: *Dry storage – open bags of dry pasta without being dated, container of dried raisins not securely covered to prevent potential contamination and *Walk in refrigerator had open and/or uncovered food items without dates – bag of hashbrowns, cooked piece of meat, crab and meat patties, churros, lava cakes and French fries. The areas of concern were discussed with Staff 1 (Culinary Director), Staff 2 (Lead Cook) and Staff 3 (Executive Director) on 05/19/26 and the findings were acknowledged at 12:45 pm.

Plan of Correction

Deficiency #1: Stainless Steel Wall Behind Cooking Equipment with Drips of Grease 1. What actions will be taken to correct the rule violation for each example? The stainless steel wall behind the cooking equipment was thoroughly cleaned and degreased immediately upon identification of the deficiency. Kitchen staff were instructed on proper cleaning procedures and expectations for maintaining cleanliness in food preparation areas. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure quarterly deep cleaning is consistently completed by an outside vendor, including routine cleaning of the stainless steel walls behind cooking equipment. If the vendor is unavailable on the scheduled date, services will be rescheduled as soon as possible to maintain compliance. In addition, staff will receive ongoing education regarding sanitation standards, proper kitchen cleaning practices, and accountability for maintaining a clean and sanitary environment. Staff will complete and sign off on daily and weekly cleaning checklists at closing. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring the corrections are completed and monitored on an ongoing basis. Deficiency #2: Exterior Area of Hood Over Cooking Equipment with Grease and Handprints 1. What actions will be taken to correct the rule violation for each example? The exterior area of the hood over the cooking equipment was thoroughly cleaned and degreased immediately upon identification of the deficiency. Staff were reminded of sanitation expectations and proper cleaning procedures for kitchen equipment and surrounding surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure quarterly deep cleaning by an outside vendor, including routine cleaning and inspection of exterior hood surfaces during daily closing duties. If the vendor is unavailable on the scheduled date, services will be rescheduled as soon as possible to maintain compliance. Staff will receive ongoing education regarding sanitation standards, proper cleaning techniques, and accountability for maintaining a clean kitchen environment. Daily and weekly cleaning checklists will be completed and signed off at closing. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator, and/or designee will be responsible for ensuring the corrections are completed and monitored on an ongoing basis. Deficiency #3: Side of Steamer – Food Splatters 1. What actions will be taken to correct the rule violation for each example? The side of the steamer with visible food splatters was immediately cleaned, scrubbed, and sanitized upon identification of the deficiency. Staff were reminded of proper cleaning procedures and the importance of maintaining all kitchen equipment in a sanitary condition, including hard-to-reach and high-use surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that steamers and all cooking equipment are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques for equipment surfaces. Daily and weekly cleaning checklists will be completed and signed off to ensure accountability. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #4: Sides of Grill and Deep Fat Fryer – Drips of Grease 1. What actions will be taken to correct the rule violation for each example? The sides of the grill and deep fat fryer were immediately cleaned, degreased, and sanitized upon identification of the deficiency. Staff were instructed on proper cleaning procedures and the importance of maintaining all cooking equipment surfaces in a sanitary condition during and after each use. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that grills and deep fat fryers are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques for high-use equipment. Daily and weekly cleaning checklists will be completed and signed off at closing to ensure accountability and consistency. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #5: Front of Deep Fryer and Refrigerator on Cooking Line – Smears/Drips 1. What actions will be taken to correct the rule violation for each example? The front of the deep fryer and refrigerator on the cooking line were immediately cleaned, degreased, and sanitized upon identification of smears and drips. Staff were reminded of proper sanitation procedures and the importance of maintaining cleanliness on all high-touch and high-visibility kitchen surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that the front surfaces of the deep fryer and refrigerator are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques. Daily and weekly cleaning checklists will be completed and signed off at closing to ensure accountability and consistency. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #6: Cutting Board on Service Line – Scored and Stained 1. What actions will be taken to correct the rule violation for each example? The cutting board on the service line that was found to be scored and stained was immediately removed from service. It was replaced with a clean, sanitary cutting board that meets health and safety standards. Staff were instructed on proper inspection of food contact surfaces and the importance of replacing damaged or heavily worn equipment promptly. 2. How will the system be corrected so this violation will not happen again? A routine inspection process has been implemented to ensure all cutting boards are checked regularly for scoring, staining, and wear. Damaged boards will be replaced immediately as needed. Staff will receive ongoing training on sanitation standards and proper maintenance of food contact surfaces to prevent cross-contamination risks. 3. How often will the area needing correction be evaluated? Food contact surfaces, including cutting boards, will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #7: Slicer Not Covered When Not in Use 1. What actions will be taken to correct the rule violation for each example? The slicer was immediately cleaned, sanitized, and properly covered upon identification of the deficiency. Staff were reminded that all food preparation equipment must be cleaned, sanitized, and covered when not in use to maintain safe food handling practices. 2. How will the system be corrected so this violation will not happen again? The kitchen procedures have been reinforced to ensure the slicer is included in the daily cleaning, sanitizing, and end-of-shift equipment shutdown checklist. Staff will receive ongoing education on safe food handling practices, including proper equipment covering and storage when not in use. Compliance will be reinforced through daily shift checklists and supervisory oversight. 3. How often will the area needing correction be evaluated? The slicer and surrounding food prep area will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrective actions are completed and consistently monitored. Deficiency #8: Dry Storage – Open Bags of Dry Pasta Not Dated; Container of Dried Raisins Not Securely Covered 1. What actions will be taken to correct the rule violation for each example? The open bags of dry pasta were immediately sealed, labeled, and dated upon identification of the deficiency. The container of dried raisins was discarded due to being improperly stored. Staff were reminded of proper dry storage procedures, including labeling, dating, and ensuring all food items are stored in covered, sanitary containers. 2. How will the system be corrected so this violation will not happen again? The dry storage area procedures have been reinforced to ensure all food items are properly labeled, dated, and stored in sealed, food-safe containers immediately upon opening. Staff will receive ongoing education on dry storage standards, including first-in-first-out (FIFO) practices and contamination prevention. Daily and weekly storage audits will be conducted to ensure compliance. 3. How often will the area needing correction be evaluated? Dry storage areas will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #9: Walk-In Refrigerator – Open and/or Uncovered Food Items Without Dates 1. What actions will be taken to correct the rule violation for each example? All open and/or uncovered food items in the walk-in refrigerator were immediately covered, labeled, and dated upon identification of the deficiency. This included bags of hashbrowns, cooked meat items, crab and meat patties, churros, lava cakes, and French fries. Any items that could not be verified for safe storage or proper dating were discarded. Staff were reminded of proper food storage procedures, including labeling, dating, and ensuring all food items are properly covered to prevent contamination. 2. How will the system be corrected so this violation will not happen again? The walk-in refrigerator procedures have been reinforced to ensure all food items are properly labeled, dated, and stored in covered, food-safe containers immediately after preparation or opening. Staff will receive ongoing education on food safety standards, including proper cooling, storage, and first-in-first-out (FIFO) practices. Daily and weekly refrigerator audits will be conducted to ensure compliance. 3. How often will the area needing correction be evaluated? The walk-in refrigerator will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored.

Visit Number
2
Visit Date
7/30/2026
Corrected Date
N/A
Details

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

Z0142
Severity Level: 2
Visits: 2
Scope
L2 Widespread
Visit Number
1
Visit Date
5/19/2026
Corrected Date
N/A
Details

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Plan of Correction

Please referencing to tag C0240

Visit Number
2
Visit Date
7/30/2026
Corrected Date
N/A
Details

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: