Health inspection·January 27, 2026

The following reflects the findings of the California Department of Public Health (CDPH) during the annual recertification survey. Survey ID: 1DE3BE-L1 Representing the Department, HFE II #49652 State Citation B was written 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 12/23/2025 at 9:58 a.m., CDPH made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to obtain the required written emergency authorization, building permit, construction approval, and attain substantial compliance from the California 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) prior to the installation of a temporary emergency generator (device for generating electricity that is used in the event of a power outage) and associated electrical alterations, including connections to the facility’s automatic transfer switch (ATS, device that shifts a facility’s power from the main utility to an emergency generator when the primary power source fails). As a result, 36 residents were placed at risk of accidents from the unauthorized installation of the temporary emergency generator system. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 12/23/2025 at 11:02 AM with ADM 1, ADM 1 stated the temporary generator is connected to the permanent generator. During an interview on 12/23/2025 at 11:06 AM with ADM 1, ADM 1 stated he confirmed there is no HCAI permit for the temporary generator. During an observation on 12/23/2025 at 11:09 AM with the MS at the generator area, the surveyor observed the temporary generator connected to the main permanent generator, automatic transfer switch (ATS, device that shifts a facility’s power from the main utility to an emergency generator when the primary power source fails), and annunciator panel (device that indicates the emergency generator’s operating status[LR1][TU2]). The following interviews were conducted with Administrator: On 12/23/2025 at 11:26 AM with ADM 1, ADM 1 stated the facility had difficulty obtaining parts for the permanent generator but did not know exactly what part was broken. On 12/23/2025 at 11:29 AM with ADM 1, a request for invoices, reports, and documentation for installation of the temporary generator was made. The facility was not able to provide documentation of the installation of the temporary generator. On 12/23/2025 at 11:54 AM with ADM 1, ADM 1 stated the previous Administrator (ADM 2) stated the permanent generator is old and had trouble finding parts for repair. On 12/23/2025 at 12:28 PM with ADM 1 and MS, MS stated he does not know if the permanent generator receives power. The MS also stated he does not know if the permanent generator would work if they disconnected the temporary generator. The ADM stated he thinks the permanent generator would not work. The following interviews were conducted as follows: On 12/23/2025 at 12:31 PM, an interview with MS was conducted. MS stated the generator provides power to offices, lights, everything that runs on electricity, red outlets, fire alarm system, boilers, and oxygen concentrators (medical devices that filter and concentrate oxygen from room air to provide supplemental oxygen to residents with respiratory conditions). On 12/23/2025 at 12:47 PM, an interview was conducted with ADM 1, ADM 1 who stated he has not spoken to anyone from HCAI yet, he has only started the process online. On 12/23/2025 at 2:27 PM, an interview with ADM 1 was conducted who stated the temporary generator was installed on 1/7/2025. The ADM 1 also stated the engine magneto part was not found. On 12/23/2025 at 2:45 PM, an interview was conducted with ADM 1, who stated they never replaced the engine magneto for the permanent generator. A phone interview on 12/23/2025 at 2:53 PM with ADM 2, ADM 2 stated the facility’s permanent generator failed to hold a charge during testing and found to be inconsistent, turning on and off, in 1/2025. ADM 2 also stated the emergency generator was not working properly. An interview on 12/23/2025 at 4:03 PM with ADM 1, ADM 1 stated the facility has six residents that would rely on emergency power because they are on oxygen concentrators. Further interview on 12/23/2025 at 4:08 PM with ADM 1, ADM 1 stated he is responsible for obtaining permits from HCAI and that it is important to notify HCAI to stay within regulations and for resident safety. On 12/23/2025 at 4:16 PM another interview with ADM 1, ADM 1 stated he thought the generator was all part of one permit and did not think to notify HCAI at the time for the temporary generator. On 12/24/2025 at 8:45 AM a follow up interview was conducted with ADM 1, a request for the permanent and temporary generator’s manufacturer instructions were made. The facility was not able to provide the permanent and temporary generator’s manufacturer instructions. Another interview on 12/24/2025 at 9:35 AM with ADM 1, ADM 1 stated, “The old administration did not let the department (CDPH) know of the changes [to the facility]. They were unaware of the need to notify [the department of changes to the facility].” ADM 1 further stated not notifying the department “Could potentially lead to safety concerns if CDPH is unaware of the facility changes and not part of the permitting process.” On 12/24/2025 at 9:45 AM, ADM 1 further stated the permanent generator is old and “Had issues with the carburetor and fuel pump. Magneto was faulty… and so had a temporary generator installed. The project currently with HCAI was for a transfer switch upgrade, not the [temporary generator].” When asked why the facility did not apply for a permit for the new generator, ADM 1 stated, “He does not know why the old administration would not submit to HCAI about this. Their Facility Consultant (FC) did help them apply for the [transfer switch] project.” During a phone interview on 12/24/2025 at 10:02 AM with FC, FC stated, “I was not made aware of the [temporary] generator. They did not use my consultation services for that. I have been trying to close this [transfer switch] project for months now.” The following documents were reviewed as follows: The facility’s P&P titled, “Preventative Maintenance Program,” last revised 12/19/2022, the P&P indicated, “A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public… The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.” The facility’s policy and procedure (P&P) titled, “Unusual Occurrence,” last revised 6/23/2025, the P&P indicated, “It is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence… An unusual occurrence report will be retained on file in the facility for one year from the date of occurrence… In addition, any power outage related to a planned PSPS (Public Safety Power Shutoff) event is considered an unusual occurrence which is reportable as required in Title 22 California Code of Regulations.” The facility’s P&P titled, “Emergency Power,” last revised 12/19/2022, the P&P indicated, “It is the policy of this facility to provide emergency power when normal power supplies are disrupted without adversely affecting the operation of the facility or the wellbeing of residents… The generator engine will be maintained and serviced per manufacturer’s instructions.” The facility’s P&P titled, “Alternate Sources of Energy,” last revised 6/30/2025, the P&P indicated, “We have mitigated the impact of a power outage on these systems through the use of a standby generator, battery operated emergency equipment, which complies with all federal, state and local regulations.” The facility’s P&P titled, “Portable Generator,” last revised 12/19/2022, the P&P indicated, “The generator will be operated, tested, and maintained in accordance with manufacturer, local and/or state requirements. All documentation related to testing and maintenance shall be maintained for three years in the Maintenance Office.” The facility failed to obtain the required written emergency authorization, building permit, construction approval, and attain substantial compliance from HCAI prior to the installation of a temporary emergency generator and associated electrical alterations. As a result, 36 residents were placed at risk of accidents from the unauthorized installation of the temporary emergency generator system. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. [LR1]The following interviews were conducted with ADM: [TU2R1]Comment added