Other·July 24, 2023

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. On 6/26/2023, an unannounced visit was conducted at the facility to investigate a complaint about the facility's physical environment. The facility failed to obtain required written authorization, building permits, or attain construction approval for the alterations/renovations/construction in the facility from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development - OSHPD). HCAI is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to 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. This failure had a direct relationship to the health, safety, and security of the residents, staff, and visitors occupying the facility. During a complaint investigation visit to the facility on 6/26/2023, the facility Administrator (ADM) was interviewed at 10:12 a.m. regarding the alteration/renovation/construction work done in the facility. The following alterations/renovations/construction work were not done in compliance with HCAI: 1. OSHPD/HCAI Non-Compliant Item #1 – During a review of HCAI “Fire and Life Safety Report – Notice of Non-Compliance”, dated 6/26/2023, authored by HCAI Fire Life Safety Officer/Fire Marshal (FLSO), project number “INV-2023-00041” indicated that the FLSO “noted the existing fire resistive floor-ceiling assembly ceiling has been removed in various areas of the basement without authorization thereby diminishing the required fire resistance of the horizontal assembly. Due to the reduced fire resistance, the Facility was requested to commence with a “Fire Watch” program”. During a concurrent observation and interview with the ADM and Maintenance Supervisor (MS) on 6/26/2023, at 11:02 a.m., inside the plastic barrier at the lower level, the evaluator observed unfinished construction with wooden floor-ceiling assembly. There were also construction materials and equipment stored in the area. The ADM stated that the contractors “started working on it over the weekend”, on “the 24th” [6/24/2023]. The ADM confirmed that the contractor removed the floor-ceiling assembly in the lower level. The contractors “come in at night” to not disturb the facility operation. During a review of the facility floor plan titled, “Lower Level”, undated, the plan identified the areas where the facility removed floor-ceiling assembly as the “Maintenance Supplies” room, corridor outside the “Maintenance Supplies” room, and the “CLASS-ROOM”. During a review of approved facility floor plan titled, “BASEMENT FLOOR PLAN”, dated 1/6/1986, the plan identified the areas where the facility removed floor-ceiling assembly as the “NURSES LOUNGE”, corridor outside the “NURSES LOUNGE”, and a “STORAGE” room. During an interview on 6/26/2023, at 12:27 p.m., the MS stated that the area under construction was used as a staff lounge and confirmed that it was noted as “CLASS-ROOM” on the undated floor plan. The MS stated that the ceiling was being repaired and that it “does not have dry wall”. During an interview on 6/26/2023, at 12:30 p.m., the MS stated that the area under construction was used as “housekeeping supplies room” and confirmed that it was noted as “Maintenance Supplies” on the undated floor plan. The MS described the ceiling in the “Maintenance Supplies” room and corridor as having “no dry wall”. During an interview on 6/26/2023, at 12:51 p.m., the FLSO stated that the contractors “took out the floor-ceiling assembly” on the lower level and that the facility “need to be on fire watch”. The FLSO asked the MS for a copy of architectural plans for the construction/alterations on the lower level. The MS responded, “No plans, no nothing”. During an interview on 6/26/2023, at 1:26 p.m., the FLSO stated that the removal of fire rated ceiling was a “big deal”. 2. OSHPD/HCAI Non-Compliant Item #2 – During a review of HCAI “Fire and Life Safety Report – Notice of Non-Compliance”, dated 6/26/2023, authored by HCAI FLSO, project number “INV-2023-00041” indicated that the FLSO “noted the removal of both bearing and non-bearing walls in various basement areas without authorization or approvals from OSHPD. Some of the removed walls were observed with “Struct 1” plywood between the wood stud framing and the gypsum plaster wall finishes which appeared to indicate a possible shear wall has been altered or removed, as well”. During a concurrent observation and interview with the ADM and MS on 6/26/2023, at 11:02 a.m., inside the plastic barrier at the lower level, the evaluator observed unfinished construction with wood stud framing and exposed wires. The ADM stated that the contractors took “down the dry wall because of damaged walls” and “instead of patching”, “will put new drywall and paint it”. The wires were capped and a licensed electrician “will put electric back”. The ADM explained, “that’s why we enclosed both sides” of the construction area. During a review of the facility floor plan titled, “Lower Level”, undated, the plan identified the areas under construction as the “CLASS-ROOM”, “Maintenance Supplies”, corridor outside “Maintenance Supplies”, and “ARCHIVES”. During a review of the approved facility floor plan titled, “BASEMENT FLOOR PLAN”, dated 1/6/1986, the plan identified the areas under construction as a “STORAGE” room, “NURSES LOUNGE”, corridor outside “NURSES LOUNGE”, and another “STORAGE” room. During a concurrent observation and interview with the ADM and MS on 6/26/2023, at 11:26 a.m., the evaluator observed a floor plan posted on the wall in the unfinished construction area in the lower level. The floor plan had black and yellow markings indicating the area of construction/alterations. During an interview on 6/26/2023, at 12:27 p.m., the MS stated that the area under construction was used as a staff lounge and confirmed that it was noted as “CLASS-ROOM” on the undated floor plan. The MS stated that the contractors were “replacing the old damaged dry wall” and that there were “visible wires on the wall”. During an interview on 6/26/2023, at 12:30 p.m., the MS stated that the area under construction was used as “housekeeping supplies room” and confirmed that it was noted as “Maintenance Supplies” on the undated floor plan. The MS stated that the contractors were to “replace drywall, whatever is damaged” and that there were “visible wires” on the walls. During an interview on 6/26/2023, at 1:11 p.m., the ADM stated that they “will stop everything” and that they “will get an architect”. The FLSO explained that the facility removed a “bearing wall” on the lower level “that is supporting the floor above”. During an interview on 6/26/2023, at 1:26 p.m., the FLSO stated that removal of a bearing wall was a “big deal”. The FLSO explained, the facility replaced the header but “don’t know if the header is right” and “who knows how everything is done”. During a review of facility’s Structural Engineer (FSE) Report, dated 6/29/2023, the report indicated that the FSE “visually inspected the altered portions of the multi-level health-care building facility” on 6/27/2023, “with the following findings and recommendations”. It is “determined that two bearing wood wall sections at the first level had been removed and replaced with wood header beams approximately spanning 12-ft and 16-ft wide. However, it is believed that this alteration does not meet building code requirements and in-order to mitigate the situation and to temporarily shore the structure”. During an interview on 6/29/2023, at 12:12 p.m., the facility Project Manager/Contractor (PM) stated that he visited the facility on 6/27/2023 with the FSE and that the FSE advised the facility “to make the current situation structurally sound until we can produce permits from HCAI”. The PM stated that the facility “didn’t get approval from HCAI” for the additions installed at the lower level and explained, “we are making it structurally sound” “because prior it might not have been or not as much as it is now”. During a review of HCAI “Fire and Life Safety Report – Notice of Non-Compliance”, dated 6/29/2023, authored by HCAI FLSO, project number “INV-2023-00041” indicated that the FLSO “noted additional shoring and supports have been installed with sill plates and expansion anchors at locations where existing walls had been removed. Informed by the Facility that a Structural Engineer has reviewed and directed the work, however the direction has not been reviewed by OSHPD and required inspection and/or special inspection does not appear to have been provided”. During a concurrent observation and interview with the FLSO on 6/29/2023, at 10:14 a.m., the evaluator observed wooden posts and wooden diagonal bracing at the lower level where it indicated “CLASS-ROOM” on the undated floor plan (“STORAGE” room on the approved plan). The evaluator also observed wooden posts and wooden diagonal bracing at another area separating the corridors by the lobby on the lower level. The FLSO stated that the facility added lateral restraint and bracing on the walls. During an interview on 7/6/2023, at 2:47 p.m., the FLSO stated that the facility’s exit floor plan was different from the facility’s as-built conditions. During a review of HCAI FLSO facility plan review, dated 7/6/2023, the FLSO identified “removed apparent bearing wall section with temporary shoring” and “removed wall section with two-sided plywood sheer panels” on the facility’s lower level (basement). During a concurrent observation and interview with HCAI District Structural Engineer (DSE) and HCAI Area Compliance Officer (ACO) on 7/7/2023, at 11:24 a.m., the DSE stated that the facility removed a shared wall at the lower level pointing to the floor markings and wall pattern next to the “Maintenance Supplies” room (noted as “NURSES LOUNGE” on the approved plan). The evaluator observed areas on the floor without floor covering with evidence of removed wall next to the “Maintenance Supplies” room. The ACO stated that he was concerned for the possible presence of asbestos and “electrical issues” on the lower level. The evaluator observed unfinished construction with wood stud framing and exposed wires on the lower level. During a review of HCAI Construction Advisory Report, dated 7/7/2023, authored by HCAI DSE, project number “INV-2023-00041” indicated that the DSE “observed removal of a portion of a double sheathed shear wall” and “removal of bearing walls in two locations” in the basement. During a review of HCAI Construction Advisory Report, dated 7/7/2023, authored by HCAI ACO, project number “INV-2023-00041” indicated that the ACO noted the following: i. “Observed removal of interior walls which included a double sheathed shear wall, removal of bearing walls in two locations as well as interior partition walls, associated electrical, mechanical, and plumbing utilities, were removed and/or altered”. ii. “Since the full scope of work and/or alterations performed without benefit of plan approval, construction permits, field inspections and material tests; the facility representee was advised to have the appropriated design professionals perform a thorough assessment of the area in question, to ensure the overall safety of the building and its occupants, as well as reporting their findings to HCAI”. iii. “Due to the age of the facility and the possibility of asbestos within the building’s construction materials and work area, the owner and/or their design professional of record must provide conformation to HCAI and CDPH that there is no asbestos within the existing building materials. Asbestos laden materials and the areas where it resides must be well-defined and documented, to assure that it has not been exposed or disturbed due to this unauthorized construction”. iv. “Most immediate issues to be addressed are the removal of any structural walls and alterations to utilities as well as ensuring that there are no exposed and/or disturbed asbestos, which may impose a danger to the construction workers, facility staff and its patients”. 3. OSHPD/HCAI Non-Compliant Item #3 – During a review of HCAI “Fire and Life Safety Report – Notice of Non-Compliance”, dated 6/26/2023, authored by HCAI FLSO, project number “INV-2023-00041” indicated that the FLSO “noted that with the removal and addition of framed walls in the basement area, the means of egress has been altered and/or obstructed without required authorization, review, permits or approvals from OSHPD”. A) During a concurrent observation and interview with the ADM and MS on 6/26/2023, at 10:54 a.m., at the lower level outside the kitchen, the evaluator observed along the corridor were two tables, two chairs, a refrigerator, a microwave, and a cabinet. At the end of the corridor, there was a closed door separating the area. Once the door was opened, the evaluator observed a plastic barrier with red zipper and red tape. The ADM stated that they were painting and upgrading storage areas in the lower level. During a concurrent observation and interview with the ADM and MS on 6/26/2023, at 11:02 a.m., inside the plastic barrier at the lower level, the evaluator observed unfinished construction with wood stud framing. The ADM stated that the contractors took “down the dry wall because of damaged walls” and “instead of patching”, “will put new drywall and paint it”. During an observation on 6/26/2023, at 11:26 a.m., the evaluator observed a floor plan posted on the wall in the unfinished construction area in the lower level. The floor plan had black and yellow markings indicating the area of construction/alterations. The floor plan illustrated different wall locations for “CLASS-ROOM”, “Maintenance Supplies”, and “ARCHIVES” on the lower level. The evaluator informed the MS and ADM of the findings. During a concurrent observation and interview with the MS on 6/26/2023, at 12:27 p.m., the MS stated that the area under construction was used as a staff lounge and confirmed that it was noted as “CLASS-ROOM” on the undated floor plan. The evaluator observed unfinished wall construction with exposed wood stud framing in the “CLASS-ROOM” area. The MS stated that the contractors were “replacing the old damaged dry wall”. During a concurrent observation and interview on 6/26/2023, at 12:30 p.m., the MS stated that the area under construction was used as “housekeeping supplies room” and confirmed that it was noted as “Maintenance Supplies” on the undated floor plan. The evaluator observed unfinished wall construction with exposed wood stud framing in the “Maintenance Supplies” area. The MS stated that the contractors were to “replace drywall, whatever is damaged”. During a concurrent observation and interview on 6/26/2023, at 12:33 p.m., the evaluator observed a plastic barrier separating a storage area to the lower-level construction area. There was no wall separating the storage area. The MS stated that behind the plastic barrier were medical records. The MS also confirmed that the area was noted as “ARCHIVES” on the undated floor plan. During an interview on 7/6/2023, at 2:47 p.m., the FLSO stated that