Health inspection·August 14, 2024

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: 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. 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling, or alterations to such facility. § 72657. Mechanical Systems. Heating, air conditioning and ventilating systems shall be maintained in normal operating conditions to provide a comfortable temperature and shall meet the requirements of Section T17-105, Title 24, California Administrative Code. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. On 7/3/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint allegation regarding physical environment. The facility failed to obtain written authorization or approval from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development of OSHPD) prior to the use of portable air-conditioning (ac- a machine that forces cool air into a building) units and upcoming repair of a broken ac unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility. During an observation on 7/3/2024 at 3:30 p.m. in the hallway, two (2) large fans were observed actively blowing air in an angle facing the ceiling. During an observation on 7/3/2024, at 3:32 p.m., observed rooms 40, 42, 39, and 41 with portable AC unit actively operating. Observed the portable AC units’ ducts (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. During an interview with the Administrator (ADM) on 7/3/2024 at 4:35 p.m., the ADM stated the facility is using four (4) portable AC units and two (2) large industrial sized fans in the hallway to keep air moving. The ADM stated he was aware that one AC unit was not functioning one week ago. The ADM stated he did not report the broken AC unit and use of portable AC units to CDPH. During an interview with the Director of Nursing (DON) on 7/3/2024 at 5:25 p.m., the DON stated that the expected temperature for the day (7/1/2024) is 108 degrees Fahrenheit. That the facility’s city location is placed under extreme heat advisory (excessive heat warning) which could affect how comfortable a resident is and their safety. The DON stated that the safety concerns could lead to dehydration, which DON defined as loss of body fluids, dry mouth, and confusion. During an interview with Maintenance Director (MD) on 7/3/2024 at 4:52 p.m., the MD stated that if there is a construction job, HCAI needs to be informed to obtain permits (an authorization or consent to do something). During a concurrent interview and record view with the ADM on 7/3/2024 at 5:21 p.m., , reviewed the facility’s AC repair contract dated 7/1/2024. The contract, signed by the ADM on 7/3/2024 indicated “Excludes:” …OSHPD (formerly HCAI) requirements.” The ADM stated the facility did not obtain permission from HCAI to use portable AC units. The ADM stated the reason for obtaining permits from HCAI is to make sure the work is done well and is according to the specifications and regulations. The ADM stated that if the work is not done correctly, it can have a negative effect and place the facility’s residents and staff in a dangerous situation. During a review of a facility provided policy and procedure titled Emergency Work Authorization dated 6/15/2022 indicated “Most work in hospital requires a permit. This includes construction as well as replacement of equipment.” The policy indicated, (a) All repair projects are subject to prior plan review, plan approval, and construction permit by the Office except as noted in subsection (b). (b) For emergency repairs carried out without the Office plan review and permit in the aftermath of an emergency, an application for plan review must be submitted with construction documents, fees and a letter of transmittal stating the reasons for emergency repairs. Photographs if available, and reports of damage and repair should also be submitted with the application. The policy also stated, “The facility may take the necessary emergency actions to abate and make safe the emergency condition that poses an imminent danger to life, injury, or property damage. Such emergency actions may proceed prior to contacting HCAI and the HCAI Regional Compliance Officer (RCO) must be contacted immediately thereafter.” It is the facility’s responsibility to notify the California Department of Public Health (CDPH) Licensing and Certification of the emergency condition and affects to the facility’s operations and their request to HCAI to approve the emergency repair, replacement, or temporary equipment project. The facility failed to obtain written authorization or approval from the Department of HCAI prior to the use of portable air-conditioning units and upcoming repair of a broken ac unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility. The above violations had a direct relationship to the health, safety, and security of the residents, staff, and visitors occupying the facility.