Other·September 20, 2022

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 7/29/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about physical environment. The facility failed to obtain the required construction sign-off final approval from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Healthcare Planning and Development [OSHPD] - HCAI 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 multiple installations and alterations performed in the facility without the required inspection, review and approval from HCAI. As a result, all residents were placed at risk of accidents from unauthorized equipment and constructions. On 8/10/2022, at 12:30 p.m., the evaluator conducted a joint inspection with the HCAI Fire Marshal I (FM) at the facility. At the time of the investigation, the Administrator (ADM), maintenance supervisor (MS) and General Contractor were present and reviewed two reports both titled, “Fire and Life Safety Report – Field Visit Report” (Project numbers U160051-19-00 and U160052-19-00), dated 2/3/2022, and authored by HCAI Fire Marshal I (FM). The reports indicated the following: a) 4/28/14 - Noted new louvered vents have been installed in the exterior wall directly adjacent to the existing generator #2 without required review, permits or approvals from OSHPD. On 5/24/16, 10/20/21, and 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160051-19-00), dated 8/10/2022, indicated, “8/10/22-No changes or progress noted” for the above-mentioned items. b) 4/28/14 - Noted the installation and apparent replacement water piping and valves without required review, permits or approvals from OSHPD. The piping installation appears to be related to the incomplete ceiling patches discussed in Section II Comment #6 of this report, as well. 4/28/14 - Newly installed piping and valves in the ceiling space above the exit access corridor.” On 5/24/16, 10/20/21, and 2/3/22 -No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160051-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. c) 4/28/14 - Noted the installation of new floor covering in several areas without required review or approvals from OSHPD. On 5/24/16, 10/20/21, and 2/3/22, no changes or progress noted. d) 5/24/16 - Noted installation in progress of exterior lighting and other electrical alterations by private licensed alarm company without required authorization, permits or approvals from OSHPD. On 10/20/21 and on 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160051-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. e) 5/24/16 - Noted the installation of magnetic door locking devices and automatic door operators on various doors in the means of egress without required authorization, permits or approvals from OSHPD. Rear exit door with automatic door operator installed without required authorization or approvals from OSHPD. Exit door with magnetic door locking device installed without authorization or approvals from OSHPD. Also, noted the fire resistive membrane of the corridor wall has been compromised or removed and covered with a plywood door as shown below. On 10/20/21 and 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160051-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. f) 1/9/13-Noted the installation of wall-hung flat panel televisions in several locations, some of which appear to weigh over 20 pounds such as the large TV installed in the Activity Room, as well as a flat panel TV of articulating arms in patient rooms with new electrical receptacles and appurtenances without OSHPD plan approval, inspection, testing or approvals. “Note: this deficiency was first observed by the OSHPD ACO in patient rooms 152, 154, 156, 158 and 150 on his Field Visit Report of 9/9/2011. On 5/24/16, 10/20/21 and 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. g) 1/9/13 - Noted installation, upgrade and/or alteration of the fire alarm system without apparent required permits, plan approval, inspection, testing or approvals. In the attic space, for example, fire alarm cable conductors were noted as not secured or installed in a neat workman-like manner and have not been protected from damage, as well. On 4/28/14, 5/24/16, 10/25/21, and 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. h) 1/9/13 - Noted various penetrations of the bottom membrane of the fire resistive roof-ceiling assembly, such as apparent room exhaust fans and ducting for portable AC (Air Conditioning) appliances, that were missing the required fire damper and/or smoke/fire damper and appears to have been altered without required review, permits or approvals from OSHPD. On 4/28/14, 5/24/16, 10/20/21, and 2/3/22 - No changes or progress noted. On 8/10/2022, at 2:30 p.m., during an interview, the HCAI FM stated there was no progress noted for compliance with this violation and confirmed that the facility did not obtain a permit for removal of the unauthorized AC appliances. i) 1/9/13 - Noted installation of new, added and/or altered electrical circuits, including the non-compliant use of non-metallic sheathed cable, excessive lengths of unsecured flexible metal conduit, unsecured/unsupported boxes and the use of unapproved “Tiger-Grip” boxes without required review, permits or approvals from OSHPD. On 4/28/14 - No changes or progress noted, and additional areas were observed this day with excessive lengths of unsupported flexible metal conduit. On 5/24/16, 10/20/21, and 2/3/22 - No changes or progress noted. j) 1/9/13 - Noted the installation of an apparent security surveillance system and other electrical cabling in the exit access corridor that penetrates the fire resistive roof/ceiling assembly without required review, permits or approvals from OSHPD. On 4/28/14 - No changes or progress noted, and additional incorrect and unprotected penetrations were noted in various areas this day, as well. On 5/24/16, 10/20/21, and 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted, except that as informed by the facility, the cameras have been removed. Informed the facility that removal of the unauthorized work without required review and authorization will not “Clear” the deficiency” for the above-mentioned items. k) 1/9/13 - Noted various areas where fire resistive assemblies appear to have been disassembled, altered, patched, or otherwise not been maintained and the fire resistance diminished or reduced. The bottom membrane of the roof/ceiling assembly in the corridor, for example, was noted as having been retextured and with patches without review, knowledge, or approvals from the OSHPD Fire Marshal. 4/28/14 - No changes or progress noted, and additional areas were observed patched or in the process of being patched without review or approval from OSHPD. On 5/24/16, 10/20/21, and 2/3/22 - No changes or progress noted. On 8/10/2022, at 2:55 p.m., during observation and interview with the ADM and MS, no changes or progress were noted, and they were unable to provide any documentation indicating the required review, permits or approvals were obtained from HCAI/OSHPD as stipulated in the HCAI Fire Marshal Report, dated 2/3/2022. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22 - No changes or progress noted” for the above-mentioned items. l) 4/28/14- Noted the installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals. Examples of water heaters installed without required permits or approvals were noted manufactured in 9/2009 and 10/2013 as shown below. 5/24/16-No changes or progress noted. Also, OSHPD Project Number X160002-19-00 has been issued for the replacement of 1 patient care water heater at the same location. The installation and placement into service of the new appliance has, again, been performed without required OSHPD review or approvals. See the FV Report dated this day for X160002-19-00 for additional comments and observations. 10/20/21-Noted Project X160002-19-00 has been closed “Non-CBSC Compliant” on 7/30/2018. OSHPD Project S170172-19-00 was issued under an “Emergency Request to Replace Damaged Water Heater”, but that project was closed “Non-CBSC Compliant” on 7/3/2017, as well. Currently, OSHPD Project S190390-19-00 issued under an “Emergency Request to Replace Damaged Water Heater” is in progress but was last reviewed by the OSHPD CO over one year ago on 10/15/2020. Project S200360-19-00 issued under an “Emergency Request to Replace Damaged Water Heater” for the laundry is in progress but was last reviewed by the OSHPD CO over one year ago on 10/22/2020. On 2/3/22 - No changes or progress noted. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22-No changes or progress noted. Project X160002-19-00 to replace the Patient Car Water Heater has not been completed or approved and has been “Closed Non-CBSC Compliant.” Projects S190390-19-00 Clinical Water Heater, and S200360-19-00 Laundry remain the only active projects to address this concern, leaving at least three unauthorized water heating appliances.” for the above-mentioned items. m) 4/28/14 - Noted the installation of several new and/or replacement rooftop HVAC [heating, ventilation, and air conditioning systems] equipment or systems without required permits, plan approval, inspection, testing or approvals from OSHPD. On 5/24/16 - No changes or progress noted. On 10/20/21- OSHPD Project S163472-19-00 was opened on 12/27/2016 to address this concern, however, the project was canceled by the facility on 4/27/2017. OSHPD Project S170982-19-00 was opened on 5/5/2017 but remains at 8% complete as of this day.” On 8/10/2022, at 3:15 p.m., during observation and interview with the ADM and MS, no changes or progress were noted, and they were unable to provide any documentation indicating the required permits, plan approval, inspection, testing, or approvals were obtained from HCAI/OSHPD as stipulated in the HCAI Fire Marshal Report, dated 2/3/2022. According to the MS, five out of 34 units had been replaced. A review of the HCAI FM’s report titled, “Fire and Life Safety Report – Field Visit Report” (Project number U160052-19-00), dated 8/10/2022, indicated, “8/10/22-OSHPD Project S170982-19-00 remains in progress to address this deficiency. Informed by the Facility that five of the appliances have been replaced” for the above-mentioned items. n) 1/29/14- In addition to the unauthorized HVAC equipment installation noted above, appurtenances and related ducting have been replaced and/or altered without required inspection, review, permits or approvals from OSHPD. Replacement ductwork was noted incorrectly installed with excessive lengths of factory-made flexible ducting and noted missing dampers at several penetrations in the ceiling membrane of the fire resistive roof-ceiling assembly. 10/20/21 - OSHPD Project S163472-19-00 was opened on 12/27/2016 to address this concern, however, the project was canceled by the Facility on 4/27/2017. OSHPD Project S170982-19-00 was opened on 5/5/2017 but remains at 8% complete as of this day.” o) 4/28/14 - Noted improper and inadequate storage of compressed gas cylinders in an exterior enclosure that included an unapproved combustible wood roof structure that has been installed without required review, permits or approvals from OSHPD. The medical gas bottles have not been properly secured and were observed with one chain that does not provide adequate support to prevent tipping especially during a seismic event. Note: As informed by the Facility Administrator, the fixed medical gas piping system is not currently in use due to leaks and maintenance issues. On 5/24/16 and 10/20/21- No changes or progress noted. On 8/10/2022, at 3:30 p.m., after observations of all the above-mentioned changes/installations, the ADM and MS, were unable to provide documentation indicating the required review, permits, or approvals were obtained from HCAI/OSHPD as stipulated in the HCAI Fire Marshal reports. The facility failed to obtain the required construction sign-off final approval from HCAI, previously known as OSHPD for multiple installations and alterations finished in the facility without the required inspection, review, and approval from HCAI. As a result, all residents in the facility were placed at risk of accidents from the installation and use of the trailer mounted temporary emergency generator. This violation had a direct relationship to the health, safety, and security of all residents in the facility.