Other·March 11, 2026

The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: 2785634 Complaint Survey ID: 1F248C-H1 Representing the Department: HFE I #53376 State Citation B was written Title 22 Article 6 Physical Plant 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter I, Division 17. Part 6. Title 24, California Administrative Code [Reference: 2022 California Building Code Section 1225.2 - New buildings and additions, alterations, or repairs to existing buildings subject to licensure shall comply with applicable provisions of the California Electrical Code, California Mechanical Code, California Plumbing Code and California Fire Code (Parts 3,4, 5 and 9 of Title 24)] and requirements of the State Fire Marshal. 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. On 3/2/2026 at 8:58 a.m., the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint regarding the physical environment. The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development [OSHPD], the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare facilities to comply with State Building Codes) for roofing repairs exceeding 300 square feet (sq ft). The facility also failed to notify the Department within five days of the commencement of any construction, remodeling, or alterations to the facility. As a result,106 residents were placed at risk of accidents from the unauthorized roofing repairs. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 3/2/2026 at 9:04 a.m. with the Assistant Administrator (AADM), the AADM stated the facility patched its roof a few months ago and that the Administrator (ADM) would be more familiar with the repairs. During interviews on 3/2/2026 with the Director of Environmental Services (DES), the following were stated: A. At 9:19 a.m., the DES stated the facility's roof was repaired in 11/2025 because of leaks that occurred from rain. The DES stated there have been no additional roof repairs aside from the repairs conducted in 11/2025. B. At 9:21 a.m., the DES was asked if the facility had obtained approval from HCAI for the roof repairs conducted in 11/2025. The DES stated, "Not that I know of." The DES also stated they do not know the square footage of the roof repairs that were conducted in 11/2025 and that it would be the ADM's job to obtain HCAI approval. C. At 9:24 a.m., the DES stated they do not know the exact materials used for the 11/2025 roof repairs. D. At 9:25 a.m., the DES stated, "[The roof] starts to get old and it has to be repaired." The DES also stated it is not their [DES] job to contact HCAI. During interviews on 3/2/2026 with the ADM, the following were stated: A. At 9:32 a.m., the ADM stated the 11/2025 roof repair was conducted due to leaks from rain and that they do not have any documentation of approval, authorization, or permits from HCAI for the roof repair because, "It was a repair...not a replacement of the roof." B. At 9:33 a.m., the ADM stated the facility has a regional maintenance consultant that assists with HCAI-related correspondence. The ADM also stated that they [ADM] did not know that roof repairs over 300 sq ft require HCAI approval. C. At 9:35 a.m., the ADM stated they are not aware of any HCAI correspondence regarding the 11/2025 roof repair and that they defer to the regional maintenance consultant to see if HCAI approval is needed. D. At 9:38 a.m., the ADM stated they are not sure of the exact materials used for the roof repair and that the materials are probably what is indicated on the roof repair agreement ["Roof Repair Agreement No. RS 21240"]. E. At 9:43 a.m., the ADM was verbally requested to provide any HCAI correspondence or documentation for the 11/2025 roof repair. During a review of the facility's record titled, "Roof Repair Agreement NO. RS 21240," dated 11/3/2025, the record indicated, "Specifications: Repair roof areas, A, B, C & D and perform a general roof maintenance on roof penetrations described below and as identified on drawing... 2. Install Modified bitumen [durable, multi-ply, asphalt-based system designed for flat or low-slope roofs] roof system onto areas A, B, C, D. Install new membrane [a waterproof material layer mainly installed on low-slope or flat roofs to prevent water infiltration] and seal to adjacent roof system. 3. Install modified bitumen roofing membrane. 4. All four area's A, B, C and D will be sealed to vents and mechanical equipment in areas... 6. Use [roof sealant, a waterproof material used to fill gaps, cracks and seams in roofing materials] on all pipes, vents and penetrations." During a concurrent observation and interview on 3/2/2026 at 9:47 a.m. with the DES on the facility's roof, there was a white-colored sealant applied to the bases of mechanical equipment and roof penetrations (objects or structures that pass through the roof's surface, such as ducts, pipes, and vents) throughout the roof. The DES stated the white-colored sealant was applied by the roofing company during the 11/2025 roof repair. During a concurrent observation and interview on 3/2/2026 at 9:52 a.m. with the DES at the southeastern area of the facility's roof, there was a rectangular section of the roof with gray-colored roof membranes that were lighter in color than the surrounding areas of the roof. The rectangular section of lighter, gray-colored membranes was bordered by a white-colored sealant, which sealed it to the surrounding areas of the roof. The bases of roof equipment and penetrations inside and outside the area were sealed with a white-colored sealant. The DES stated that the lighter, gray-colored section of the roof was one of the roof areas repaired in 11/2025. The DES measured the area of the lighter, gray-colored section of the roof and stated that it was 28 feet (ft) 11 inches (in) by 10 ft four in (an area of approximately 298.8 sq ft). The area is located approximately above Resident Rooms 39, 41, and 43 and corresponds to roof area "B" on "Roof Repair Agreement NO. RS 21240". During a concurrent observation and interview on 3/2/2026 at 9:56 a.m. with the DES at the southwestern area of the facility's roof, there was a rectangular section of the roof with gray-colored roof membranes that were lighter in color than the surrounding areas of the roof. The rectangular section of lighter, gray-colored membranes was bordered by a white-colored sealant, which sealed it to the surrounding areas of the roof. The bases of roof equipment and penetrations inside and outside the area were sealed with a white-colored sealant. The DES stated that the lighter, gray-colored section of the roof was one of the roof areas repaired in 11/2025. The DES measured the area of the lighter, gray-colored section of the roof and stated that it was 26 ft six in by eight ft seven in (an area of approximately 227.5 sq ft). The area is located approximately above Resident Rooms 17, 19, and 21 and corresponds to roof area "D" on "Roof Repair Agreement NO. RS 21240". During a concurrent observation and interview on 3/2/2026 at 10:01 a.m. with the DES at the western area of the facility's roof, there was a rectangular section of the roof with gray-colored roof membranes that were lighter in color than the surrounding areas of the roof. The rectangular section of lighter, gray-colored membranes was bordered by a white-colored sealant, which sealed it to the surrounding areas of the roof. The bases of roof equipment and penetrations inside and outside the area were sealed with a white-colored sealant. The DES stated that the lighter, gray-colored section of the roof was one of the roof areas repaired in 11/2025. The DES measured the area of the lighter, gray-colored section of the roof and stated that it was 32 ft four in by 11 ft six in (an area of approximately 371.8 sq ft). The area is located approximately above Resident Rooms 3, 5, and 7 and corresponds to roof area "C" on "Roof Repair Agreement NO. RS 21240". During a concurrent observation and interview on 3/2/2026 at 10:04 a.m. with the DES at the northern area of the facility's roof, there was a rectangular section of the roof with gray-colored roof membranes that were lighter in color than the surrounding areas of the roof. The rectangular section of lighter, gray-colored membranes was bordered by a white-colored sealant, which sealed it to the surrounding areas of the roof. The bases of roof equipment and penetrations inside and outside the area were sealed with a white-colored sealant. The DES stated that the lighter, gray-colored section of the roof was one of the roof areas repaired in 11/2025. The DES measured the area of the lighter, gray-colored section of the roof and stated that it was 26 ft seven and a half in by 29 ft one in (an area of approximately 774.3 sq ft). The area is located approximately above Resident Rooms 57 and 59 and corresponds to roof area "A" on "Roof Repair Agreement NO. RS 21240". During an interview on 3/2/2026 at 12:23 p.m. with the ADM, the ADM stated they are aware that it is required to obtain approval or permits from HCAI for renovations, alterations, or repairs to the building. During a concurrent interview and record review on 3/2/2026 at 12:24 p.m. with ADM, the facility's record titled, "Roof Repair Agreement NO. RS 21240," dated 11/3/2025, was reviewed. The record indicated, "Specifications: Repair roof areas A, B, C & D.... as identified on drawing." The record indicated four rectangular roof repair areas (labeled "A", "B", "C", and "D") on an image of the building's roof. The record did not indicate the exact square footage of the roof repairs, but the drawings of the repair areas (to scale [represented in proportional dimensions] with the building's roof) indicated the repairs exceeded 300 sq ft. The ADM stated the facility's regional maintenance consultant said that they did not get HCAI approval since the roof work is less than 300 sq ft. The ADM was asked if the consultant was referring to the roof repair work listed on "Roof Repair Agreement NO. RS 21240" and the ADM stated they [regional maintenance consultant] were. The ADM also stated that it was the regional maintenance consultant who provided the record to them [ADM]. During interviews on 3/2/2026 with the ADM, the following were stated: A. At 12:25 p.m., the ADM stated it would be important to contact HCAI regarding the roof repairs because, "It's a regulatory requirement." The ADM also stated that going through the process is important to ensure building integrity. B. At 12:26 p.m., the ADM stated it is important to use the proper materials when repairing the roof because you would want to use the appropriate material for the scope of work, which are compliant with regulatory requirements such as fire and safety. C. At 12:27 p.m., the ADM was asked what issues could arise from unapproved renovations or alterations to the facility and the ADM stated, "There is potential for anything to happen." D. At 12:28 p.m., the ADM stated they are aware that the facility needs to notify the Department prior to commencing construction or alterations to the facility and that they [ADM] are not sure what communication with the Department was done. The ADM was asked who in the facility is responsible for notifying the Department and the ADM stated, "Probably me." E. At 12:29 p.m., the ADM stated it is supposed to be [DES] that contacts HCAI. F. At 12:33 p.m., the ADM was verbally requested to provide correspondence or documentation of approval from HCAI for the 11/2025 roof repair. The ADM stated there is no HCAI correspondence for the roof repairs. The ADM was also verbally requested to provide documentation or correspondence for giving notice to the Department for the 11/2025 roof repair. The ADM stated that there is probably not any correspondence with the Department and that they [ADM], "At least didn't do it." G. At 1:52 p.m. with the ADM, the ADM stated the 11/2025 roof repair started on 11/8/2025 and finished on 11/16/2025. The ADM stated that 11/18/2025 is the invoice date and that they [ADM] obtained the information from calling the roof repair company who conducted the 11/2025 roof repair. During a review of HCAI Report Center (a public website that displays all HCAI projects for a listed facility) as of 3/2/2026, there were no open or closed projects associated with the facility's 11/2025 roof repair. During a review of the facility's record titled, "Invoice # 4202," dated 11/18/2025, the record indicated, "Description Material Delivery/Commencement of Work Roof repair completed 11/18/2025 as per contract RS 21240." During a review of the facility's policy and procedure (P&P) titled, "Physical Environment," reviewed 7/11/2025, the P&P indicated, "Policy: The facility will be equipped and maintained to protect the health and safety of residents, personnel and the public." During a review of the facility's P&P titled, "General Maintenance," reviewed 7/11/2025, the P&P indicated, "Maintenance will ensure that inspection and services are provided to repair and maintain all functional equipment." The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from HCAI for roofing repairs exceeding 300 sq ft. The facility also failed to notify the Department within five days of the commencement of any construction, remodeling, or alterations to the facility. As a result, 106 residents were placed at risk of accidents from the unauthorized roofing repairs. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.