Health inspection·July 3, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: CA00965926. Complaint Event ID: 7T6I21 Representing the Department, HFEI # 49896 State Citation B was written. 22 CCR §72637. General Maintenance. (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. 22 CCR §72641. Emergency Lighting and Power System. (b) The licensee shall provide and maintain an emergency electrical system in safe operating condition and in compliance with subsections (d), (e), and (f). The system shall serve all lighting, signals, alarms and equipment required to permit continued operation of all necessary functions of the facility for a minimum of six hours. On 6/5/2025, at 10:13 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding damaged floor joists (horizontal beam that acts as the support structure for a floor or ceiling) and a non-existent one-hour fire resistant (a material, assembly, or construction that can withstand the effects of a fire for at least one hour without collapsing or allowing the fire to penetrate, as determined by standardized fire tests) floor-ceiling assembly (a combination of structural elements that create a horizontal barrier between a floor below and a ceiling above). The facility failed to: 1. Maintain the emergency generator in good repair, free from oil leaks, and keep the surrounding area free of accumulated oil. 2. Maintain the fire-resistive rating (the time in minutes or hours that a building component can withstand fire exposure while maintaining its structural integrity and ability to resist the passage of fire, smoke, and heat) for a floor-ceiling assembly between the first floor and basement level of the facility. As a result of failing to maintain the emergency generator in good repair and failing to maintain the required fire-resistive floor-ceiling assembly, all residents, staff, and visitors were placed at risk from fire and smoke hazards, as well as the potential for uncontrolled smoke spread and the failure of fire alarm and sprinkler devices to operate as required. Furthermore, the failure to maintain the emergency generator in good repair could lead to its failure, preventing it from supplying essential electrical services, thereby affecting the care and needs of all residents in the facility. 1. During a review of HCAI's "Construction Advisory Report - Investigation", dated 6/4/2025, indicated, in the facility's basement level within the Main Sprinkler Valve/Cart Storage room were "damaged wood joist that appeared to have smoke/fire residue". During an observation on 6/5/2025 at 10:15 a.m. with the Maintenance Supervisor (MS), HCAI District Structural Engineer (HCAI DSE), and Administrator in training (AIT) in the facility's basement level, there were wood beams with black residue in the Main Sprinkler Valve room. During an interview on 6/5/2025 at 10:22 a.m. with HCAI DSE, he stated that oil may be leaking from the emergency generator onto the secondary beams (a support beam in a building structure) below. He does not believe fire damage caused the blackened beams in the basement level. During a review of HCAI's "Construction Advisory Report - Investigation", dated 6/5/2025, indicated, "Observed the space above ceiling in the basement room called "Main Sprinkler Valve - Cart Storage". Several locally blackened areas were observed in wood joists. Signs of leaks from the above was also observed, possibly bringing oil/water from above. The area above (in the first floor) is near building entrance and a generator room. Pool of oil was observed sitting in the generator room above ... it is recommended that the facility consult with a structural engineer to do a detailed investigation to identify the underlying cause(s), extend of the water/oil leak and/or blackened surfaces potentially from a fire, and provide repair recommendation, as applicable". During an observation on 6/5/2025 at 10:24 a.m. with the MS in the emergency generator room, there was fluid residue on the exterior of the emergency generator. There was also fluid accumulated on the ground and around the emergency generator. During an interview on 6/5/2025 at 11:24 a.m. with the MS, the MS stated that the facility's emergency generator underwent a 4-hour load test (a test that requires the generator to run at a specific load [electrical demand placed on the generator] continuously for four hours to verify the generator's ability to operate consistently and reliably under sustained demand) on 6/4/25, during which the leak was detected. The MS stated that the facility wants to replace the emergency generator but was unsure when that will happen. According to the MS, Generator Technician 1 (GT 1) informed him that the 4-hour load test caused the leak. He also stated that the emergency generator is fueled by gasoline (gas). During an interview on 6/5/2025 at 12:03 p.m. with HCAI Regional Compliance Officer (HCAI RCO), he stated that he noticed the leak around the emergency generator when he was at the facility on 5/2/2025. He also stated that when he was at the facility during the 4-hour load test on 6/4/2025, he noticed the leak again and that it smelled like gas. HCAI RCO stated that the generator technician informed him that fluid "might be spitting out" from the top of the emergency generator. During an interview on 6/5/2025 at 12:30 p.m. with the MS, the MS stated that GT 1 identified the need to repair the gaskets to fix the leak but did not specify what was leaking. He contacted the generator company for the 4-hour load test report, but they had not sent the report. The MS stated that the facility will get the emergency generator serviced. During an interview on 6/5/2025 at 2:59 p.m. with the MS, the MS stated that if the emergency generator is leaking gas, there is a risk for fire, which could spread to the lower floor and throughout the facility. During an interview on 6/5/2025 at 3:36 p.m. with GT 1, he stated that there was an oil leak from the breather (a relief valve or vent for the generator's engine), and he preferred to pull the emergency generator and take it off-site to be repaired to ensure there were no additional leaks. He stated that if the oil leak leads to low oil levels, the emergency generator could overheat or burn itself out, causing the generator to not function. He stated that the repair could be done on-site, but he would need to perform a diagnosis. He also stated that the issue involves the gaskets but was unsure which gaskets. During an interview on 6/6/2025 at 12 p.m. with the MS, the MS stated that he conducts a 30-minute load test (running the generator under a load for at least 30 minutes) every week and was unaware of the leak until the 4-hour load test. He also stated that the emergency generator is connected to the emergency lighting and red outlets. During an observation on 6/10/2025 at 11:30 a.m., there was a temporary generator on wheels in the parking lot behind the generator room. Generator Technician 2 (GT 2) was on site working on emergency generator. During an interview on 6/10/2025 at 12:11 p.m. with the ADM, she stated that the emergency generator would provide power for emergency lighting and medical equipment in the event of an emergency. The red outlets would supply power to oxygen equipment, medical devices, low-air mattresses, BiPAP (Bilevel Positive Airway Pressure, is a type of non-invasive ventilation used to assist breathing), and CPAP devices (Continuous Positive Airway Pressure device, is a machine that delivers a continuous flow of pressurized air to keep a person's airway open during sleep). The ADM stated that one resident was on BiPAP, one was on CPAP, and 13 residents were on low air mattresses. However, the ADM did not specify how many residents were using oxygen equipment. During a review of the facility's record titled, "Facility Assessment Tool", updated on 5/3/2025, the assessment tool indicated examples of special treatment and conditions, along with the average number of residents receiving each treatment: seven residents with oxygen therapy, two with BIPAP and CPAP, and 14 receiving tube feeding (delivers liquid nutrition directly into the stomach or small intestine via a tube, bypassing the mouth and esophagus) or parenteral nutrition (provides nutrients directly into the bloodstream, bypassing the entire digestive system). During a concurrent observation and interview on 6/10/2025 at 12:52 p.m. with GT 2, GT 2 was on site working on the emergency generator. He stated that he had to clean the oil off the generator to determine the source of the leak. He stated that he was still assessing the issue and could not specify the exact location of the problem. During a review of the facility's policy titled, "Emergency Generator or Alternate Energy Source", revised 4/2019, the policy indicated, "If there is a disruption in the normal power supply, alternate sources of energy will be used to maintain subsistence needs such as food, water, medical supplies, emergency lighting, temperature, refrigeration, fire systems, sewage and waste disposal". The policy also indicated, Permanent generators will be used in accordance with National Fire Protection Association (NFPA) 110 and Life Safety Code requirements, including location, testing, fuel storage and maintenance. During a review of the facility's "Emergency Operations Program and Plan Manual", undated, the policy on Emergency Power indicated, the following services shall be powered by the Emergency Generator: Exit Lights, Emergency "Call" System, Fire Alarm System, Fire and/or Smoke Barrier Doors, Hallway Lights (every third light fixture), Electrical Outlets (usually colored red), Refrigerator for Medicine, and Electrical Doors (locked facilities). The policy also indicated optional Services powered by the Emergency Generator: Public Address System, Refrigerator and Freezer, and Elevator. 2. During an observation and interview on 6/5/2025 at 10:21 a.m. with the AIT at the basement level of the facility, there were several missing tiles in the ceiling which exposed wood members, pipes, and sprinkler heads. The AIT stated that a flood had damaged the ceiling, and that the facility had not started with the repairs. During an interview on 6/5/2025 at 11:50 a.m. with HCAI RCO, he stated that the ceiling in the facility's basement was missing the required one-hour fire rating. During an interview on 6/5/2025 at 12:03 p.m. with HCAI RCO, he stated that the facility should go on fire watch (the assignment of a person or persons to an area to actively monitor for fire hazards, potential fires, or other life safety dangers when a fire protection system is impaired) because the facility cannot ensure a one-hour fire rating for the ceiling in lower level. During an interview on 6/10/2025 at 12:47 p.m. with the ADM, she stated that the facility would begin Firewatch today (6/10/2025). During a review of HCAI's "Construction Advisory Report - Investigation", dated 6/4/2025, indicated, "With the ceiling tiles removed from the suspended ceiling the fire alarm and fire sprinkler devices will not operate as required for a smooth ceiling in accordance with NFPA (National Fire Protection Association) 13 and NFPA 72" and "With the exposed floor/ceiling assembly as well as the impairment of the fire alarm system and fire sprinkler suppression system, in accordance with CFC 901.7 fire watch shall be implemented to protect the facility until these are restored." During a review of the facility's policy titled, "Maintenance Service", revised 12/2009, the policy indicated the following: A. "The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times." B. "Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. c. Maintaining the fire alarm system and emergency generator system in good working order." C. "The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner." In violation of the above cited standards, the facility failed to: 1. Maintain the emergency generator in good repair, free from oil leaks, and keep the surrounding area free of accumulated oil. 2. Maintain the fire-resistive rating for a floor-ceiling assembly between the first floor and basement level of the facility. As a result of failing to maintain the emergency generator in good repair and failing to maintain the required fire-resistive floor-ceiling assembly, all residents, staff, and visitors were placed at risk from fire and smoke hazards, as well as the potential for uncontrolled smoke spread and the failure of fire alarm and sprinkler devices to operate as required. Furthermore, the failure to maintain the emergency generator in good repair could lead to its failure, preventing it from supplying essential electrical services, thereby affecting the care and needs of all residents in the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.