Other·September 21, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Investigation #: CA00858758 Representing the Department, HFEI 43229 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: 2019 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. On 9/1/2023, an unannounced visit was conducted at 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 the following: 1) Change-of-use of facility's utility room to an Information Technology (IT) Server Room with installation of wall mounted servers, equipment, and related appurtenances. 2) Installation of security surveillance system, patient monitoring system and wall mounted television (TV) in the facility. 3) Installation of replacement water heaters in the facility. 4) Installation of several new and/or replacement Heating Ventilation and Air Conditioning (HVAC) systems on the facility's roof. 5) Installation of recessed lighting fixtures in the facility. 6) Installation of new and/or altered electrical panels, conductors, and data cabling in the facility. 7) Installation of an unsecured ice machine in the facility's kitchen area. 8) Apparent renovation of the facility's central Nurse Station. 9) Removal of an apparent fire resistive door in the facility's basement exit access corridor 10) Proposed construction of an electrical/telecommunication room that did not reflect the existing "as-built" condition of the building, especially with regards to the horizontal fire resistive floor ceiling design. 1) OSHPD/HCAI Non-Complaint Work 1 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's Fire Marshal (FM), indicated that "change of use of an apparent clean utility room to an IT (Information Technology) Server Room with the installation of wall mounted servers, equipment and related appurtenances without required review, permits or approvals from OSHPD." There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023 at 12:18 p.m., with the ADM, VPO, RMD, and RMS, outside the IT server room, the evaluator observed a label indicating "Unity Room". In the room were cabinets, sink, faucet fixture, wall mounted soap dispenser, and wall mounted paper towel dispenser. There were towers of electronic devices, electronic devices mounted on the wall, and numerous cabling connections in the room. There were also unsealed penetrations with cables going through the wall. The electronic devices were in-use at the time of observation. The RMS confirmed the findings. During an interview on 9/1/2023 at 2:40 p.m., with the ADM, VPO, and RMD, the RMD stated that the facility has assigned an architect for the projects, however, the contract has not been finalized and has not been signed by the architect. Once finalized, the architect will open a project and submit plans. The RMD confirmed, there was no project currently opened with HCAI to correct unapproved change of use of utility room to IT server room and installation of equipment and servers in the room. 2) OSHPD/HCAI Non-Complaint Work 1 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's Fire Marshal (FM), indicated that "installation of an apparent security surveillance system, patient monitoring system and several wall mounted televisions without required review, permits or approvals from OSHPD." There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. A. During a concurrent observation and interview on 9/1/2023 at 10:15 a.m., with the facility Administrator (ADM) and Fire Department Inspector (FDI), in the facility's basement, the evaluator observed security cameras along the corridor at the following locations: near the elevator, outside the soiled laundry room, and outside the rehabilitation room. The ADM confirmed findings. The ADM stated, he does not know if the facility had opened a project to get the installation of security cameras in compliance with HCAI. During a concurrent observation and interview on 9/1/2023, with the ADM, Vice President of Operations (VPO), Regional Maintenance Director (RMD), and Regional Maintenance Supervisor (RMS), the evaluator observed the following and was confirmed by the RMS: a. At 12:06 p.m., there were security cameras on the ceiling near the central nursing station. The RMD stated, the facility architect should have opened a project with HCAI and that he will check on the status of the project. b. At 12:09 p.m., there was a security camera on the ceiling outside the business office. c. At 12:10 p.m., there were security cameras on the ceiling inside the activity/recreational room. d. At 12:12 p.m., there were security cameras on the ceiling outside rooms 133 and 135. e. At 12:16 p.m., there was a security camera on the ceiling outside room 125. f. At 12:17 p.m., there was a security camera on the ceiling outside room 120. g. At 12:18 p.m., there was a security camera on the ceiling outside room 118. h. At 12:22 p.m., there were security cameras on the ceiling outside rooms 105, 107, and 114. B. During a concurrent observation and interview on 9/1/2023 at 12:10 p.m., with the ADM, VPO, RMD, and RMS, the evaluator observed a wall mounted TV inside the activity/recreational room. The RMS confirmed observation. C. During a concurrent observation and interview on 9/1/2023, with the ADM, VPO, RMD, and RMS, the evaluator observed the following and was confirmed by the RMS: a. At 12:10 p.m., there was a wall mounted computer tablet device inside the activity/recreational room. The ADM stated that the computer device is being used by staff for charting (documentation of services provided during patient's care). b. At 12:16 p.m., there was a computer charting device mounted along the corridor wall outside room 132. c. At 12:17 p.m., there were computer charting devices mounted along the corridor wall outside rooms 120 and 123. d. At 12:21 p.m., there were computer charting devices mounted along the corridor wall outside room 116. e. At 12:22 p.m., there was a computer charting device mounted along the corridor wall outside room 112. During an interview on 9/1/2023 at 2:40 p.m., with the ADM, VPO, and RMD, the RMD stated that the facility has assigned an architect for the projects, however, the contract has not been finalized and has not been signed by the architect. Once finalized, the architect will open a project and submit plans. The RMD confirmed, there was no project currently opened with HCAI to correct unapproved installation of security cameras, wall mounted TVs, and computer charting device (patient monitoring system). 3) OSHPD/HCAI Non-Complaint Work 2 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, indicated that "installation of several replacement water heaters, at least one of which was manufactured in April 2013, have already been placed in service without required permits, plan approval, inspection, testing or approvals". "Project X230043-19-00 and X230044-19-00 have been opened for the replacement of two of the unauthorized water heaters ... The required Construction Start form (form required by HCAI to be filled up prior to the start of construction. This include facility information, detailed project description of the work to be performed, construction start date, contractor information, and contract cost. )... has not been received, yet the scope of work appears to have been completed and the appliances placed into service without addressing the missing floor-ceiling assembly, shaft deficiencies and without OSHPD review or approvals." Initial non-compliance was indicated on 11/14/2013. Floor-ceiling assembly is a term used to describe how a floor/ceiling is built. Assembly is a unit or structure composed of a combination of materials or products, or both. Assemblies have different fire ratings. Fire resistance is the ability of a material, product, or assembly to withstand fire or give protection from it for a period of time. During a concurrent observation and interview on 9/1/2023 at 10:26 a.m., with the ADM and FDI, the evaluator observed missing acoustical ceiling tiles (tiles used to cover ceilings) with exposed pipes and wooden membrane of the floor-ceiling assembly (the construction of the ceiling to the floor above) in the laundry room. Inside the laundry room were washers, dryers, and water heaters. The evaluator observed three water heaters in use, water heater 1 with serial number E23-01198 (Manufactured 5/2023), water heater 2 with serial number D13-1636 (Manufactured 4/2013), and water heater 3 with serial number F11-3682 (Manufactured 6/2011). The ADM confirmed observation. The ADM stated, he does not know anything about the required construction start form that was not submitted to HCAI and that the water heater project was treated separately from the missing floor-ceiling assembly. The FDI explained, "each step needs HCAI approval." During an interview on 9/1/2023 at 2:40 p.m., with the ADM, VPO, and RMD, the RMD stated, "I don't believe they have submitted the construction start form, the only thing we have is building permit." 4) OSHPD/HCAI Non-Complaint Work 3 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, indicated that "installation of several new and/or replacement HVAC (Heating, Ventilation, and Air Conditioning) systems without required permits, plan approval, inspection, testing or approvals from OSHPD." There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023 at 11:15 a.m., with the ADM, Regional Maintenance Supervisor (RMS) and FDI, the evaluator observed multiple HVAC units installed on the roof of the facility. HVAC unit 5 had a label with a manufactured date of 5/2000, HVAC unit 9 had a label with a manufactured date of 8/2009, and HVAC unit 13 had a label with a manufactured date of 3/2012. HVAC units 11 and 15 had illegible labels on them. The RMS stated that HVAC units 5, 9, 11, 13, and 15 looked newer. During a concurrent observation and interview on 9/1/2023 at 11:29 a.m., with the ADM, RMS and FDI, the evaluator observed a condensing unit (outdoor portion of an air conditioning unit) with a serial number E322100261 installed on the roof. The RMS stated that the condensing unit also looked new. The RMS stated that the facility architect "should have something submitted" to HCAI to get permits for the HVAC units. During an interview on 9/1/2023 at 2:40 p.m., with the ADM, VPO, and RMD, the RMD stated that the facility has assigned an architect for the HVAC project, however, the contract has not been finalized and has not been signed by the architect. Once finalized, the architect will open a project and submit plans. The RMD confirmed, there was no project currently opened with HCAI to correct unapproved installation of HVAC systems. 5) OSHPD/HCAI Non-Complaint Work 4 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, he noted "installation of recessed lighting fixtures in various areas of the facility without required permits, plan approval, inspection, testing or approvals from OSHPD. The installation penetrates the fire resistive roof-ceiling assembly leaving un-approved and un-protected opening, as well." There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023, with the ADM, VPO, RMD, and RMS, the evaluator observed the following: a. At 12:09 p.m., there were recessed lighting fixtures inside the business office. The RMS confirmed observation. b. At 12:10 p.m., there were recessed lighting fixtures inside the activity/recreational room. The RMS confirmed observation. c. At 12:12 p.m., there were recessed lighting fixtures inside the conference room. The RMS confirmed observation. During an interview on 9/1/2023 at 2:49 p.m., with the ADM, VPO, RMD, and RMS, the RMD stated that the facility has assigned an architect for the project, however, the contract has not been finalized and has not been signed by the architect. Once finalized, the architect will open a project and submit plans. The RMD confirmed, there was no project currently opened with HCAI to correct unapproved installation of recessed lighting fixtures in the facility. 6) OSHPD/HCAI Non-Complaint Work 5 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, he noted "installation of new and/or altered electrical panels, conductors, as well as excessive amounts of data cabling apparently related to items 1 & 2 above without required review, permits or approvals from OSHPD especially above the ceilings." There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023 at 9:36 a.m., with the ADM and FDI, the evaluator observed missing acoustical ceiling tiles with cables/wires exposed and hanging on the ceiling in the basement corridor. The ADM stated that the ceiling tiles were removed due to rainwater leaking into the basement from the storm on 8/20/2023. During an interview on 9/1/2023 at 2:49 p.m., with the ADM, VPO, RMD, and RMS, the RMD stated that there was no project currently opened with HCAI to correct unapproved installation of conductors and data cabling listed on the non-compliance report. 7) OSHPD/HCAI Non-Complaint Work 6 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, he noted "installation of an unsecured ice machine in the Kitchen area without review, permits or approvals from OSHPD". There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023 at 1:27 p.m., with the RMS, the evaluator observed an ice machine in-use in the kitchen. The RMS confirmed observation. During an interview on 9/5/2023 at 1:18 p.m., with the VPO and RMD, the RMD stated that the facility has assigned an architect for the project, however, the contract has not been finalized and has not been signed by the architect. The RMD confirmed, there was no project currently opened with HCAI to correct unapproved installation of the ice machine in the kitchen. 8) OSHPD/HCAI Non-Complaint Work 7 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/17/2023, authored by HCAI's FM, he noted "apparent renovation of the Central Nurse Station without required reviewed, permits or approvals from OSHPD". There was "No changes or progress noted." Initial non-compliance was indicated on 11/14/2013. During a concurrent observation and interview on 9/1/2023 at 12:08 p.m., with the ADM, VPO, RMD, and RMS, the evalu