Health inspection·July 14, 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 6/25/2025 at 9 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, upgrade, and/or alteration of the fire alarm system 2) Installation of several replacement water heaters 3) Installation of wall-hung flat panel TVs in resident rooms 4) Installation of security surveillance system 5) Installation of kitchen hood suppression system 6) Installation of patient monitoring system 7) Installation of several new and/or replacement Heating, Ventilation, and Air Conditioning (HVAC) systems 8) Installation or placement into service of wall mounted air-conditioning appliances 9) Incorrect application of penetration fire stopping 10) Unauthorized renovations in the main entrance lobby 11) Unauthorized electrical alterations for the lobby renovations and for the temporary reception desk at the side exit As a result, all 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 6/17/2025, authored by HCAI's Fire Marshal (HCAI FM), indicated, “Noted the installation, upgrade and/or alteration of the fire alarm system without required inspection, testing or approvals from OSHPD. Noted OSHPD Project #S220129-19-00 received plan approval on 2/22/2022, however no Field Visits were requested and the project became void on 2/22/2023.” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During an interview with the Maintenance Supervisor (MS) on 6/25/2025 at 12:24 PM, the evaluator requested HCAI approval or authorization for the installation of the current fire alarm system. During an observation on 6/26/2025 at 1:21 PM with the MS, there was an addressable fire alarm control panel (component of the fire alarm system which receives signals from initiating devices with discrete identification, and processes these signals to determine part or all of the required fire alarm system output function) located at the facility’s nursing station. During an interview with the Administrator (ADM) on 6/27/2025 at 10:03 AM, the ADM stated the facility reached out to their contractor regarding the fire alarm system dialer (radio dialer that transmits alarm signals to monitoring center). The ADM stated, “The facility didn’t receive approval from HCAI, so I believe they didn’t go through with the project.” During an interview with the ADM on 6/27/2025 at 10:05 AM, the ADM stated that he could not find any HCAI related documentation regarding fire alarm system approval. During an interview with the MS on 6/27/2025 at 1:40 PM, the MS stated the facility did not have documentation of HCAI approval or authorization for the installation or upgrade of the fire alarm system. During an interview with HCAI FM on 6/30/2025 at 11:05 AM, the HCAI FM stated that a year ago (in 2024) the facility placed the dialer into service without HCAI approval. The HCAI FM stated the facility’s project for the replacement of the fire alarm system dialer became void, “Because they never involved us. It was just the dialer, but they are having problems with the whole system.” 2) OSHPD/HCAI Non-Complaint Work 2 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals. Observed appliances installed without required OSHPD authorization were noted manufactured between 4/10/2014, 3/8/2021 and 9/27/2023...Noted the Facility opened six projects to address this deficiency, three of which have been ‘Closed Administratively’ and three have a status of ‘Pending Construction Start’.” The date of the initial non-compliance investigation was 7/2/2024. During an interview with the ADM on 6/25/2025 at 10 AM, the ADM stated, “We put in permit/work request for the repair and replacement of water heaters, but it’s still ongoing. The work was done, but HCAI never approved nor denied the permitting.” During an interview with the ADM on 6/25/2025 at 3:35 PM, the ADM stated, “Two water heater permits were approved, but due to issue between contractor and inspector, the contractor has not come back. The ADM stated he will have the contractor come out with IOR [Inspector of Record] to inspect and approve those two water heaters.” During an interview with the MS on 6/25/2025 at 11:04 AM, the MS stated Water Heater 4 provides hot water to the Laundry, and it was installed before he started working in this facility. During an interview with the MS and ADM on 6/25/2025 at 9 AM, the MS stated he started working at the facility in 8/2023. The ADM stated he started working at the facility on 6/9/2025. During a concurrent observation and interview with the MS on 6/26/2025 at 2:45 PM, Water Heater 4 was located beside the laundry room. The MS stated that Water Heater 4’s Model Number is UCG100H1993N with Serial Number ZJ52067011. During a review of the water heater manufacturer’s website retrieved on 6/27/2025, the manufacturer’s website indicated that Water Heater 4 with Serial Number ZJ52067011 was manufactured 9/27/2023. During a concurrent observation and interview with the MS on 6/25/2025 at 11:09 AM, Water Heater 5 was located beside the kitchen. The MS stated that Water Heater 5 provides hot water to the Kitchen, and that “they’re changing the exhaust. They came in last week of May (2025) to work on it”. The MS stated that Water Heater 5’s Serial Number is TD43244047. During a review of the water heater manufacturer’s website retrieved on 6/27/2025, the manufacturer’s website indicated that Water Heater 5 with Serial Number TD43244047 was manufactured 5/9/2019. During a concurrent observation and interview with the MS on 6/25/2025 at 11:17 AM in Water Heater 3’s water heater closet, Water Heater 3 was installed. The MS stated that Water Heater 3 provides hot water to the residents’ rooms. The MS stated that Water Heater 3’s model number is UCG100H2703N with serial number LC34235791. During a review of the water heater manufacturer’s website retrieved on 6/27/2025, the manufacturer’s website indicated that Water Heater 3 with serial number LC34235791 was manufactured 4/10/2014. During a review of HCAI Report Center on 6/27/2025, the report indicated that two of facility’s water heater projects were “Closed Administrative”. Project number X240067-19-00 for the “Replacement of water heater for No.3 – Clinical” was “Closed Administrative” on 12/2/2024. Project number X240068-19-00 for the “Replacement of water heater No.4 – Kitchen” was “Closed Administrative” on 12/2/2024. During an interview with HCAI FM on 6/30/2025 at 11:05 AM, HCAI FM stated that “Closed Administratively” meant that the facility did not submit plans and, “Never did anything.” 3) OSHPD/HCAI Non-Complaint Work 3 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the installation of wall-hung flat panel televisions in several locations, some of which appear to weigh over 20 pounds without OSHPD plan approval, inspection, testing or approvals.” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During an interview with the MS on 6/25/2025 at 2:27 PM, the MS stated, “Every resident room has a TV wall mount, they were already there before I started working here.” During an observation on 6/25/2025 at 2:30 PM, there were wall mounted TVs in all 63 resident rooms, with each room having one, two, or three wall mounted TVs. During an interview with the MS on 6/27/2025 at 1:40 PM, the MS stated the facility does not have documentation of HCAI approval or authorization for the installation of wall-mounted TVs in resident rooms. 4) OSHPD/HCAI Non-Complaint Work 4 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the installation of an apparent security surveillance system and several wall mounted televisions without required review, permits or approvals from OSHPD” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During an observation with the MS on 6/26/2025 at 3:55 PM in the front lobby, there was a camera on the ceiling facing the front lobby, a camera on the corridor ceiling in front of the side entrance/reception area, a camera on the ceiling between the emergency exit door and Room 47, and another camera on the ceiling between Room 36 and Room 38. During an interview with the MS on 6/26/2025 at 4 PM, the MS stated the facility has a Ring camera (security camera and video doorbell unit equipped with two-way communication) in the front lobby and a security camera on the ceiling in front of every exit. The MS stated these cameras have all been installed before he started working in the facility, and there are a total of five cameras. 5) OSHPD/HCAI Non-Complaint Work 5 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the kitchen hood suppression system 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 2022 California Fire Code requires chemical hood suppression systems to be UL-300 compliant. The installed system does not appear to be UL-300 compliant and was noted with fire sprinkler within the hood as well.” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During an interview with the MS on 6/25/2025 at 10:46 AM, the MS stated the kitchen hood was installed before he started working in the facility. During an observation with the MS on 6/25/2025 at 10:54 AM, the kitchen hood had an ANSUL R-102 Wet Chemical Fire Suppression System. The hood also had two sprinkler heads installed inside, one on each end. During an interview with the MS on 6/26/2025 at 10:38 AM, the MS stated he was unsure if the kitchen hood suppression system is connected to the facility’s fire alarm system. During an interview with the ADM on 6/26/2025 at 11 AM, the ADM stated, “We don’t have HCAI documentation for the installation of the hood.” 6) OSHPD/HCAI Non-Complaint Work 6 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted installation of an apparent patient monitoring system and wireless access points data appliances without required permits, plan review, inspection, testing or approval from OSHPD. Installation included monitors and power and data cabling in the fire resistive exit access corridors.” Fire resistive are materials designed to withstand fire and prevent its spread for a specific duration, providing more time for evacuation and minimizing structural damage. There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During a concurrent observation and interview with the MS on 6/25/2025 at 2:54 PM, there were 16 wall-mounted screens along the facility’s corridor. The wall-mounted screens were installed at the following locations: beside Room 58, beside the Activities Office, between Room 45 and 47, inside the Rainbow Room, between Rooms 40 and 38, beside Room 34, beside Room 26, beside Room 20, beside Room 19, beside Room 8, beside Room 4, beside Room 74, beside Room 66, beside Room 78, beside Room 83, and beside Room 84. The MS stated the wall-mounted screens are patient monitoring systems where the facility’s certified nursing assistants (CNAs) log patient charting. During an interview with the MS on 6/25/2025 at 2:55 PM, the MS stated in regard to the wall-mounted patient monitoring systems, “These were also installed before I started working here.” During an interview with the MS on 6/25/2025 at 3 PM, the MS stated the facility did not have documentation of HCAI approval or authorization for the installation of wall-mounted patient monitoring screens. 7) OSHPD/HCAI Non-Complaint Work 7 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the installation of several new and/or replacement HVAC systems without required authorization, permits, plan approval, inspection, testing or approvals from OSHPD. Observed appliances installed without required OSHPD authorization were noted manufactured between September 2013, May 2014, July 2014, and April 2018.” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During a concurrent observation and interview with the MS on 6/27/2025 at 12 PM, there were four HVAC units on the roof with manufacturing dates from 2013 to 2018. HVAC 1 had a label with manufacturing date of 7/2014. The MS stated that HVAC 1 services the Sunshine Room and Medical Records Room. HVAC 2 had a label with manufacturing date of 4/2018. The MS stated that HVAC 2 services Resident Rooms 32, 34, and 36. HVAC 4 had a label with manufacturing date of 5/2014. The MS stated that HVAC 4 services the Director of Nursing’s (DON’s) Room, Family Room, and Beauty Parlor. HVAC 9 had a label with manufacturing date of 9/2013. The MS stated that HVAC 9 services Shower Room 3, Shower Room 4, and Resident Room 63. During an interview with the MS on 6/26/2025 at 4:06 PM, the MS stated, “We don’t have HCAI documentation for the installation of HVAC units.” 8) OSHPD/HCAI Non-Complaint Work 8 – During a review of HCAI's Fire and Life Safety Report - Notice of Non-Compliance, dated 6/17/2025, authored by HCAI FM, indicated, “Noted the installation or placement into service wall mounted air-conditioning appliances and portable air-cooling appliances without required authorization, inspection, testing or approvals from OSHPD. Noted the apparent exhaust ducting unsupported and penetrating the fire resistive roof ceiling assemblies (the entire structure that forms the roof and ceiling of a building, including all the layers and components that provide support, insulation, weather protection, and a finished interior surface) without review or approvals, as well.” There was, "No changes or progress noted." The date of the initial non-compliance investigation was 7/2/2024. During a concurrent observation and interview with the MS on 6/25/2025 at 3:05 PM in t