Health inspection·April 2, 2025

California Code of Regulations, Title 22, §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public  § 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.   F921 Safe/Functional/Sanitary/ Comfortable Environment  On 2/14/2025 at 10:45AM, an unannounced visit was made by the California Department of Public Health [CDPH] to the facility to investigate a facility reported incident regarding Safe/Functional/Sanitary/ Comfortable Environment. The facility failed to maintain a safe environment in two of two resident’s rooms (Residents 1 and 2), residents’ shared bathroom, facility kitchen, and resident’s activity room. As a result, residents were placed at risk for injury. This had the potential for residents to be placed at risk for injury.    During an observation on 2/14/2025 at 10:43 AM in facility parking lot, plastic tarp cover was observed in various parts of the roof of the facility.  During an interview on 2/14/2025 at 10:49 AM with the director of nursing (DON), the DON stated she does not know if there is a water leak in the facility.  During an observation on 2/14/2025 at 10:51 AM in Resident 2 room bed B, the room was observed with paint bubbling around ceiling above bed B with discoloration.  During an interview on 2/14/2025 at 10:55 AM with Resident 2, Resident 2 stated on 2/13/2025 around 11 AM, water started leaking at the foot of bed B. Resident 2 stated the leak was a steady constant drip of water. Resident 2stated the staff soaked up the big puddle of water with bed linens and towels. Resident 2 stated when she walked back to her room around 12pm, she observed another water leak was over bed B. Resident 2 stated she returned to the activity room. Resident 2 stated while in the activity room at around 2 PM, there was water leaking from the ceiling by the entrance to the administration office. Resident 2 stated there was also water leaking from the ceiling of the resident shared bathroom.  During an observation on 2/14/2025 at 11:12 AM in the facility kitchen, the kitchen was observed with paint bubbling and cracking around the ceiling. The damaged ceiling is directly over the mechanical washing area (Dish machine area and three compartment sinks for pots and pans washing).  During an interview on 2/14/2025 at 11:14 AM the kitchen, the Dietary Supervisor (DS) stated the roof started leaking yesterday on 2/13/2025 around 10 AM and stated the leak was a steady constant drip of water. The staff placed a bucket underneath the area where it was leaking. The kitchen staff informed the maintenance supervisor (MS) and the Administrator (ADM) on 2/13/2025 between 10:30 AM 11:00 AM. The DS stated kitchen was in operation and prepared and served food yesterday and today. The DS further stated there is damaged to the kitchen wall and ceiling in the kitchen and should not have used the kitchen for cooking since it is not a safe environment and potential for infection control.  During an observation on 12/14/2025 at 11:21 AM in activity room, the activity room was observed with paint bubbling around an electrical outlet above the entrance to the administrative office on the ceiling.  During an interview on 2/14/2025 at 11:23 AM, with Activity Director (AD), the AD stated the roof started leaking yesterday 2/13/2025 around 11 AM, and staff placed a bucket underneath the area that was leaking.  During an observation on 12/14/2025 at 11:27 AM in the residents shared bathroom, the bathroom was observed with paint bubbling and cracks around the above the toilet area.  During an observation on 12/14/2025 at 11:32 AM in Resident 1 room bed C area, the room was observed with paint bubbling on the ceiling in multiple areas around bed C.  During a review of the facility document titled maintenance logbook for repair, dated 2/13/2025 indicated, there was a leak in Resident 2’s room bed B.  During an interview on 2/14/2025 at 11: 52AM, the MS stated he checked the maintenance log yesterday 2/13/2025 around 10 AM and saw a report that there was a leak in Resident 2’s room bed B area. The MS stated he placed a plastic tarp outside on the roof.  During an interview on 2/14/2025 at 11: 55AM, the MS stated he noticed there was a leak in the kitchen from the ceiling yesterday 2/13/2025 before noon. The MS stated the kitchen ceiling was leaking, and the drywall of the ceiling was damaged from the leak. The MS stated the dry wall was ballooned and swollen and placed a plastic tarp on the roof area. He further stated he did not do anything inside the kitchen since it was the kitchen area was wet.  During an interview on 2/14/2025 at 12:01 PM, the MS stated he noticed yesterday on 2/13/2025 sometime around noon that there was a paint bubble and crack in the resident’s shared bathroom. The MS further stated he placed a plastic tarp on the roof outside.  During an interview on 2/14/2025 at 12:04 PM, the MS stated he noticed yesterday 2/13/2025 sometime between 10 AM and 11 AM that there was a paint bubble and crack in Resident 1’s room above her bed, Bed C.  During an interview on 2/14/2025 at 12:09 PM, the MS stated he noticed yesterday around 10:30 AM there was water leak from the ceiling paint bubbling around an electrical outlet in the activity room and placed a bucket underneath the area. The MS stated he informed administrator about all the leaks at the facility yesterday. The MS stated he did not contact any outside contractor for come to check the roof.  During an interview on 2/14/2025 at 12:27 PM with LVN 1, LVN 1 stated yesterday 2/13/2025 around 10 AM LVN 1 noticed the celling in Resident 2 room bed B was leaking in and around the foot of the bed. LVN 1 stated placing some pads on the bed, and documented the information in maintenance log and informed MS.  During an interview on 2/14/2025 at 1:28 PM with the DON, the DON stated she was not aware about the leak at facility. The DON stated she was informed this morning around 10 AM that the kitchen was preparing and serving food yesterday and today.  During an interview on 2/14/2025 at 2:20 PM with ADM, the ADM stated he was informed about the leak at facility and asked the MS to place plastic tarp on the celling. The ADM stated he did not contact any contractor to evaluate the roof at this time.  During an interview on 2/14/2025 at 4:52 PM with ADM, the ADM stated he did not inform the State Agency regarding the leaks at the facility.  During a review of the facility’s P&P titled “Safety and Supervision of Residents” revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The policy indicated due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures, these risk factors and environmental hazards include the following: bed safety and electrical safety.  The facility failed to maintain a safe environment in two of two resident’s rooms (Residents 1 and 2), residents’ shared bathroom, facility kitchen, and resident’s activity room. As a result, residents were placed at risk for injury. This had the potential for residents to be placed at risk for injury.  These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.