11. Unannounced Visit: Food Deficiency

Hours:    None

Facility Type: 735 (Adult Residential)

Facility is not serving the required food groups.

Investigation Findings
Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting the initial 10 day complaint visit. LPA met with administrator. LPA explained the nature of the complaint and was assisted by administrator throughout the visit.

LPA investigated the allegation of the facility not serving the required food groups. The facility was toured and inspected, including the food storage areas, kitchen, menu reviewed, food expiration dates and general appearance were checked also. In addition, LPA interviewed several staff and clients regarding meals prepared at the facility and snacks offered in between meals. LPA observed the lunch meal that was served and discovered it was not the meal listed on the menu prepared by the registered dietician. In addition, LPA learned that certain food items on the menu are being omitted from the meals, such as the salads and fresh fruits. The menu needs to be followed to ensure all the clients are provided the recommended daily servings of each food group.

Therefore, this complaint allegation is SUBSTANTIATED. A copy of this report, LIC 9099D, LIC 421, and appeal rights are being provided and explained to administrator during the exit interview.

Deficiency Type /
Section Number
Type A
Section Cited
Meals shall be at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - for the age group served, and that foods shall be selected, stored, prepared and served in a safe and healthful manner. Certain food items are being omitted from the menus with no alternative for a replacement provided. Fresh fruits, salads, meat loaf, baked chicken, ham sandwich, and vegetable soup are all listed on the menu. These items were not prepared and were replaced with either nothing or a food item which lacked nutritional value to meet the dietary needs of the clients. Due to this being a repeat deficiency within a 12-month period, an immediate civil penalty is being assessed in the amount of $150.00.
Licensee shall ensure the approved menu is followed and prepared as stated. Any substitutions need to be of the same nutritional value as that food which is being replaced. Submit evidence that menu is being followed and balanced meals are being served each day. Photos of each meal will be forwarded to LPA for 7 days, including snacks. Penalty assessed and will accrue at $50.00 a day until corrected.


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