Health inspection·September 25, 2025

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: 2022 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 9/10/2025 at 9:10 AM, the California Department of Public Health (CDPH) made an unannounced visit to 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) Installation of several replacement water heaters, 2) Installation of a security surveillance system and several wall-mounted televisions, 3) Installation of a kitchen hood suppression system (automatic or manually activated fire protection system designed for commercial kitchens that uses a special wet chemical agent or water mist to extinguish fires, shut off gas or electricity to appliances, and prevent re-ignition), 4) Installation of several new and/or replacement heating, ventilation, and air conditioning (HVAC) systems, including window-type air conditioning appliances (single, self-contained units that exhaust heat and humidity from the room to the outside through a window), 5) Installation and placement into service of a new electrical panel (central distribution point for electricity in a building) and associated receptacles, 6) Alteration of the fire sprinkler system (building system for protecting a building against fire by means of overhead pipes which convey an extinguishing fluid such as water) as well as sprinkler heads improperly spaced in several locations, 7) Installation and placement into service of laundry equipment including the installation of polyvinyl chlorine (PVC, a versatile and durable synthetic plastic polymer used in construction) and acrylonitrile Butadiene Styrene (ABS, a strong and rigid plastic commonly used in construction) piping, 8) Renovation and/or alteration of two nurse stations as well as installation of shelving in the exit access corridor, 9) Replacement of exit signage with new fixtures with battery back-up, and 10) Installation and/or patching of areas of the existing roof covering. As a result, 236 residents were placed at risk of accidents from unauthorized equipment installation, alterations, renovations, and constructions. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents. 1) OSHPD/HCAI Non-Complaint Work 1 - During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/8/2017, authored by HCAI's Fire Marshal (HCAI FM), the report indicated, “Noted the installation of several replacement water heaters that have already been placed in service without required authorization, permits, plan approval, inspection, testing or approvals from OSHPD. At least two of the appliances observed this day were manufactured after 1/1/2014 and will, therefore, be tracked under a separate OSHPD investigation number.” During a concurrent observation and interview on 9/10/2025 at 10:20 AM with the Maintenance Assistant (MA) and Maintenance (M1) inside Water Heater Room #1, there were three water heaters. Two water heaters had rating plates indicating a manufacture date of 5/2022; one water heater had no indication of the manufacture date. The MA stated he has worked at the facility for two years. The M1 stated he has worked at the facility for about two months. The MA stated the water heaters are for laundry. During a concurrent observation and interview on 9/10/2025 at 10:31 AM with the MA and M1 inside Water Heater Room #2, there were four water heaters. All four water heaters had rating plates indicating manufacture dates in 2024. The MA stated two of the water heaters are for the kitchen and the other two water heaters are for the patient rooms in stations 1, 2, and 3. During a concurrent observation and interview on 9/10/2025 at 10:38 AM with the MA and M1 inside Water Heater Room #3, there were two water heaters. Both water heaters had a manufacture date of 4/3/2019. The MA stated the water heaters are for patient rooms in stations 4 and 5. During an interview on 9/10/2025 at 11:04 AM with the Administrator (ADM), the ADM stated he does not know who installed the water heaters, when the water heaters were installed, or why they were installed. The ADM stated he will look into it. During an interview on 9/10/2025 at 11:06 AM with the ADM, the ADM stated the facility needs to make sure the water heaters are up to safety code to make sure everything is done safely. During an interview on 9/12/2025 at 10:05 AM with the Assistant to the Administrator (AADM), the AADM stated that he has worked with the facility since 2016 and the current licensee assumed ownership of the facility on 6/14/2023. The AADM stated the two water heaters with the manufacture date of 5/2022 in Water Heater Room #1 were installed in 2022 and the water heater without a manufacture date in Water Heater Room #1 was installed in 2018. The AADM stated the water heaters with the manufacture dates in 2024 in Water Heater Room #2 were installed under the current licensee. The AADM stated he does not have documents related to the water heaters and does not remember who installed the water heaters in Water Heater Room #1. The AADM stated he lost access to the documents because the former licensee took the documents with them. During an interview on 9/12/2025 at 10:36 AM with the AADM, the AADM stated the water heaters in Water Heater Room #3 with manufacture date of 4/3/2019 were installed in 1/2020. The AADM stated he does not have documents related to the water heaters and does not remember who installed them. The AADM stated that the previous licensee took the documents with them. During a review of the facility invoices dated 1/12/2023, 5/10/2023, 6/9/2023, 4/4/2024, the invoices indicated billing for a water heater replacement project. The invoices indicated HCAI approval as part of the water heater replacement project. During a review of the HCAI building permit for project #S230567-19-00, issued on 3/22/2024, the permit indicated, “The proposed project consists of replacing (2) existing domestic hot water boilers with water heaters, associated piping and accessories. For compliance with redundancy, (2) water heaters are required for the patient room hot water and (2) water heaters are required for the dietary hot water.” During a review of the HCAI Report Center on 9/12/2025, the status of project #S230567-19-00 was changed on 4/8/2024 to, “Closed Inactive.” 2) OSHPD/HCAI Non-Complaint Work 2 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/8/2017, authored by the HCAI FM, the report indicated, “Noted the installation of an apparent security surveillance system and several wall mounted televisions without required review, permits or approvals from OSHPD.” During an observation on 9/10/2025 at 11:31 AM with the MA and M1 by the Director of Nursing (DON) office, surveillance cameras were installed. During an observation on 9/10/2025 at 11:36 AM with the MA and M1 in Resident Room 123, two wall-mounted televisions (TVs) were installed. During a concurrent observation and interview on 9/10/2025 at 11:38 AM with the MA and M1 in the corridor outside of Resident Room 121, a Dell smart monitor (type of computer monitor) was mounted on the wall. The MA stated that every station has three computer monitors and each resident room has either two or three TVs. During an observation on 9/10/2025 at 11:42 AM with the MA and M1 inside the conference room, a wall-mounted TV was installed. During an observation on 9/10/2025 at 11:43 AM with the MA and M1 inside the physical therapy room, a wall-mounted TV was installed. During an interview on 9/10/2025 at 11:56 AM with the ADM, the ADM stated the TV and computer monitor wall-mounts were installed by the previous licensee. During an interview on 9/10/2025 at 11:59 AM with the ADM, the ADM stated the security system was installed before he worked for the facility. The ADM stated he does not know who installed the security system and he does not have documentation regarding the installation of the security system or wall mounted TVs/computer monitors. During an interview on 9/10/2025 at 12:03 PM with the ADM, the ADM stated the potential concerns from unapproved security systems and wall-mounted TVs/computer monitors are not meeting building codes, electrical issues, and data issues. During a concurrent observation and interview on 9/11/2025 at 3:53 PM with the Janitor (J1) in the employee lounge, a cable wire was protruding out of a penetration inside the ceiling near the restroom. The J1 stated the hole was because there was a wall-mounted TV inside the employee lounge. During an interview on 9/12/2025 at 11:01 AM with the AADM, the AADM stated there are three generations of security cameras throughout the facility, both operable and inoperable. The AADM stated the black cameras (first generation) are older and do not work except for the one by the front entrance of the facility near the fire doors (door with a fire-resistance rating used as part of a passive fire protection system to reduce the spread of fire and smoke between separate compartments of a structure). The AADM stated the larger white cameras (second generation) throughout the facility were installed between 2015 and 2019. The AADM stated the current information technology (IT) staff installed the smaller white security camera units. The AADM stated there are a total of 15 new security cameras, with only nine currently in operation. During an interview on 9/12/2025 at 11:24 AM with the AADM, the AADM stated he does not have an HCAI permit or documents related to the surveillance cameras and TV/computer monitor wall-mounts. The AADM stated he has to contact their IT staff to get the work order and installation paperwork for the latest security cameras. During an interview on 9/12/2025 at 11:30 AM with the AADM, the AADM stated the concerns that could arise from the unapproved/unpermitted installation of surveillance cameras and TV/computer monitor wall-mounts are faulty wiring, electrical shocks, and hazards for residents, if done improperly. During a review of the HCAI Report Center on 9/12/2025, there were no open or closed projects associated with the unapproved/unpermitted installation of surveillance cameras and TV/computer monitor wall-mounts. 3) OSHPD/HCAI Non-Complaint Work 3 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/8/2017, authored by the HCAI FM, the report indicated, “Noted the kitchen hood suppression system apparently installed...without required review, permits or approvals from OSHPD. The 2007 California Fire Code required all dry and wet chemical hood suppression systems to be upgraded to compliant UL-300 systems by 12/2008, and the current 2016 California Fire Code requires chemical hood suppression systems to be UL-300 compliant…The installed system was noted with the manual activation device is installed too close to the cooking appliances.” The report also indicated, “Noted a UL300 Kitchen Hood Suppression system...that was installed without required authorization, permits or approvals from OSHPD. Also, noted the manual activation device has incorrectly been installed directly to the side of the hood or directly adjacent to the equipment which the system is to protect.” During a concurrent observation and interview on 9/10/2025 at 1:43 PM with the MA and M1 in the kitchen, the distance from the grill located under the exhaust hood to the manual activation device for the fire suppression system was measured by the MA and M1. The MA stated the distance measured is 47 inches. During a concurrent observation and interview on 9/10/2025 at 1:44 PM with the MA and M1 in the kitchen, the distance from the oven located under the hood to the manual activation device for the fire suppression system was measured by the MA and M1. The MA stated the distance measured is 45 inches. During an observation on 9/10/2025 at 1:50 PM with the MA and M1 in the kitchen, the fire suppression system displayed a tag that indicated, “UL-300.” During a concurrent observation and interview on 9/10/2025 at 1:55 PM with the MA and M1 in the kitchen, the distance from the skillet to the manual activation device for the fire suppression system was measured by the MA and M1. The skillet was the closest cooking appliance to the manual activation device located on the other side of the cook’s line. The MA stated the distance measured is 61 inches. During a review of the facility’s e-mail correspondence with the fire suppression system vendor dated 3/14/2024, the e-mail stated, “I will have a Technician out tomorrow, March 15th at 8:00am to walk with the facility with the Administrator and Maintenance Director. He [the technician] will also look at the pull station that needs to be relocated.” During a review of the facility’s signed contract with the fire suppression system vendor dated 3/20/2024, the description of work indicated, “Design and install Kitchen Hood suppression system. Design include plans with approvals from HCAI for Fire Alarm, Electrical Engineering, UL300suppression system.” During an interview on 9/12/2025 at 11:36 AM with the AADM, the AADM stated that a vendor installed the kitchen hood suppression system. The AADM stated the facility received a quote from the same vendor to relocate the manual activation device for the fire suppression system, but the current licensee did not follow through with the contract. During an interview on 9/12/2025 at 11:42 AM with the AADM, the AADM stated he does not have further documentation or work orders regarding the installation and changes quoted for the fire suppression system. During an interview on 9/12/2025 at 11:46 AM with the AADM, the AADM stated the potential concerns from the improper/unapproved installation of the kitchen fire suppression system is injury from fire, malfunctions, and the fire suppression system not working when needed in case of fire. During a review of the HCAI Report Center on 9/12/2025, there were no open or closed projects associated with the unapproved/unpermitted installation of the kitchen fire suppression system. 4) OSHPD/HCAI Non-Complaint Work 4 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 8/8/2017, authored by the HCAI FM, the report indicated, “Noted the installation of several new and/or replacement HVAC systems, including window-type air conditioning appliances…without required authorization, permits, plan approval, inspection, testing or approvals from OSHPD.” During an interview on 9/11/2025 at 12:15 PM with the Maintenance Supervisor (MS), the MS stated the previous maintenance supervisor worked at the facility for over 20 years and had all the information regarding the HVAC system. The MS stated the previous maintenance supervisor stopped working at the facility sometime in 6/2025. The MS stated he does not have any files or documents for the HVAC installation. During an interview on 9/11/2025 at 12:19 PM with the MS, the MS stated the problems that could arise from the unapproved/improper installation of the HVAC systems are fire hazards, especi