Health inspection·March 12, 2025

22 CCR § 72603. Space Conversion Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the approval of the Department. On 2/25/2025 the California Department of Public Health (CDPH) conducted a relicensing survey at the facility. Upon investigation, CDPH determined the facility converted Room 34 as a designated walkway to the smoking patio without CDPH notification and approval. During an initial tour of the facility on 2/25/2025, at 11 AM, Room 34 was observed to be a walkway to a smoking area for the residents. During a review of the facility’s Client Accommodation Analysis record (form designed to provide a record of client accommodations approved for licensed care), the record indicated the floor area for Room 34 was 91.25 square feet (sq ft, unit of measure) and the approved capacity was indicated for one resident. During a review of an email communication from the facility dated 12/16/2024 timed at 3:28 PM, the email indicated the facility’s email communication to CDPH Licensing and Certification Program Centralized Application Branch [CAB]. The email indicated that a letter dated 10/3/2024 was sent by the facility to CAB requesting to “Remove (1) bed… from Room 34.”  During a review of an email communication dated 2/14/2025 from the facility to CAB, the email indicated a new request from the facility to withdraw the previously requested bed suspension request for Room 34.  During an observation and concurrent interview with the Administrator (ADM) on 2/26/25, at 4:40 PM, while standing in the hallway of the facility, a signage posted on the door, indicating Designated Smoking Area, with the smoking schedule also indicated. Upon entering Room 34, there was no call light system or overbed lighting. The electrical outlets on the right side of the room were all covered with a wall outlet plate. A sliding patio door was observed leading to an outside smoking area. The ADM stated Room 34 should have been converted back to a resident’s room. The ADM stated if the facility would convert Room 34 back to a resident’s room, it will take the facility one week to convert Room 34 back into a resident’s room. The ADM stated he has not received an approval letter for the room conversion (Room 34) since he started working at the facility approximately 2 years ago. The ADM stated the facility would like to request bed suspension for now, because the facility may want to convert Room 34 back into a resident’s room in the future. As a result of the above violations, CDPH determined the facility converted Room 34 as a designated walkway to the smoking patio without CDPH notification and approval. These violations had a direct or immediate relationship to the health, safety, or security of residents in the facility.