Other·April 12, 2024

AMENDED 04/19/24 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. 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 4/4/2024, an unannounced visit was conducted at the facility to investigate a complaint about the facility's 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 a beam in the lobby area 2) Renovations in at least one corridor 3) Installation of at least two new electrical panels in the exit access corridors 4) Installation of a replacement commercial hood exhaust fan on the roof 5) Installation of replacement water heaters 6) Installation of one water heater appliance in an exterior enclosure 7) Installation and alteration of security cameras, wireless access points and data cabling. In addition, the facility failed to notify the Department of Public Health (DPH, Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility. This deficient practice has the potential for unapproved modifications to be improperly installed/constructed, for fire related accidents occur and be improperly contained, and for this department to be unaware of any hardships that may be experienced by the facility for the unregulated/unapproved modifications. During an interview on 4/4/2024 at 10:15 a.m. with the facility Administrator (ADM), the ADM stated that alteration/renovation/construction work was done in the facility. 1. OSHPD/HCAI Non-Compliant Item #1 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI Fire Life Safety Officer/Fire Marshal (FLSO), project number “INV-2024-00027” indicated that the FLSO, “Noted a large opening in the fire resistive exit access corridor wall with a new vinyl accordion door [a collapsible, paneled, sliding door] , thereby reducing the required fire resistance of the wall leaving the adjacent Rehabilitation Room open to the corridor without required review, permits, inspection or authorization from OSHPD.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:18 a.m. in the Lobby, the evaluator observed a vinyl accordion door installed at an opening in the corridor wall located between the Lobby and the Rehabilitation Room. The corridor wall had wooden plank casing installed along the opening. The ADM stated the opening in the corridor wall to the Rehabilitation Room was existing as it was an extension of the Lobby prior to the renovation. The ADM stated the old Rehabilitation Room was located in the room that is currently being used as the Director of Staff Development (DSD) Office. The ADM stated that the vinyl accordion door and the wooden plank casing were installed six to nine months ago by the Maintenance Supervisor (MS) to delineate the Lobby from the new Rehabilitation Room. The ADM stated that receipts and invoices from the renovation were not maintained or available. During a review of the facility floor plan, undated, the floor plan identified the “REHAB ROOM” was connected to the “LOBBY”. The plan also identified the room previously used as the Rehabilitation Room according to the ADM as “DSD / PAYROLL.” 2. OSHPD/HCAI Non-Compliant Item #2 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance,” dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted renovations in progress in at least one corridor with the installation of new gypsum board on the bottom of the fire resistive roof-ceiling assembly, patching of the corridor fire partition walls and wood backing for wall mounted handrails without required review, permits, inspection or authorization from OSHPD.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:26 a.m. in the corridor along Rooms 10 through 19, the gypsum board was painted white, the wood backing was installed for the handrails, and crown molding was installed at the juncture of the walls and ceiling. The ADM stated that the renovations were completed by the MS and an additional assistant on 2/15/2024. The ADM stated that receipts and invoices from the renovations were not maintained or available. 3. OSHPD/HCAI Non-Compliant Item #3 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted the installation of at least two new electrical panels (apparently manufactured in 2022) in the exit access corridors without required review, permits, inspection or authorization from OSHPD.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:30 a.m. in the corridor near the Minimum Data Set (MDS) Office, an electrical panel was installed on the wall. The electrical panel was equipped with an alarm that alerted when the panel was opened. The ADM stated that the electrical panel was installed in early 2023 and that he was not sure which section of the facility the electrical panel serves. 4. OSHPD/HCAI Non-Compliant Item #4 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted the installation of a replacement commercial hood exhaust fan manufactured on 6/22/2022 installed on the roof without required review, permits, inspection or authorization from OSHPD.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:38 a.m. on the roof above the Kitchen, a commercial hood exhaust fan was installed. The ADM stated that the commercial hood exhaust fan was replaced due to a failing motor. The ADM stated that he was not sure who completed the installation and whether any documentation regarding the installation was maintained as available. 5. OSHPD/HCAI Non-Compliant Item #5 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted the installation of replacement water heaters without required review, permits, inspection or authorization from OSHPD. The water heater appliances were observed not properly braced and without adequate protection at the exhaust vent penetration of the roof-ceiling assembly.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:44 a.m. in the Boiler Room, two water heaters were installed. The build date on the water heater with an accessible data plate indicated 4/26/2018; the metal braces holding both water heaters were dated 6/21/2016. The ADM stated that they were unsure when the water heaters were installed in the Boiler Room and has been this way since he has been the ADM (approximately five years). The ADM stated the water heaters are connected to the showers and sinks in the facility, excluding the Kitchen. 6. OSHPD/HCAI Non-Compliant Item #6 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted at least one water heater appliance installed in an exterior enclosure without required review, permits, inspection or authorization from OSHPD. The enclosure was observed located in the area where the original roof access ladder was installed and the ladder has been cut with the lower portion relocated to the side of the enclosure requiring maintenance personnel to walk on the top of the enclosure next to the appliance exhaust vent.” During a concurrent observation and interview with the ADM on 4/4/2024 at 10:34 a.m. at the Water Heater Enclosure connected to the Kitchen, the door to the enclosure was locked and the ADM could not locate the key. The exterior stucco walls of the enclosure were not flush and extended approximately 1/2 inches past the exterior walls of the building. The ADM stated that the water heater for the kitchen was replaced “long time ago, over a year” and that the enclosure may have been constructed when the water heater was replaced. The ADM stated that receipts and invoices from the renovations were not maintained or available. During an interview with the ADM on 4/4/2024 at 11:15 a.m., the ADM stated that the water heater for the Kitchen was in use. 7. OSHPD/HCAI Non-Compliant Item #7 During a review of HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance”, dated 2/15/2024, authored by HCAI FLSO, project number “INV-2024-00027” indicated that the FLSO, “Noted the installation and alteration of security cameras, wireless access points and data cabling without required review, permits, inspection or authorization from OSHPD.” During concurrent observations and interviews with the ADM on 4/4/2024 at 10:48 am., there was a total of nine security cameras installed in the following areas: corridor near Room 5, corridor near the Nursing Station, corridor near Room 4, corridor near Room 7, corridor near Kitchen, Dining Room, corridor in Lobby, Lobby near Rehabilitation Room, and Rehabilitation Room. Each security camera was connected to wires that extended into the wall. The ADM stated that the security cameras were installed before he became the ADM (approximately five years ago). During a concurrent observation and interview with the ADM on 4/4/2024 at 11:11 a.m. in the ADM Office, data cabling was penetrating through the corner wall of the office. The ADM stated that the cables are used for internet access. During a concurrent observation and interview with the ADM on 4/4/2024 at 11:14 a.m. in the corridor near the Nursing Station, a wireless access point was installed on the ceiling. The ADM stated that the wireless access point was installed before he became the ADM (approximately five years ago) and was replaced sometime in 2023. The ADM stated that he was unsure who replaced the wireless access point. During an interview with the ADM on 4/4/2024 at 10:55 a.m., the ADM stated that receipts and invoices from the renovations noted on HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance” were not maintained or available. During an interview with the ADM on 4/4/2024 at 10:57 a.m., the ADM stated that the facility did not seek or receive approval for the renovations noted on HCAI “Fire and Life Safety Report – Investigation Notice of Non-Compliance” and that the DPH was not notified of the renovations. During a review of the facility’s policy titled, “Conformity with Laws and Professional Standards”, revised in April 2007, the policy indicated, “Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes and professional standards of practice that apply to our facility and types of services provided.” During a review of the facility’s policy titled, “Corporate Compliance Program”, revised in March 2014, the policy indicated, “This facility is committed to compliance with all applicable laws, regulations and standards of all applicable accrediting bodies governing the programs in which the facility participates.” During a review of the facility’s policy titled, “Receipt and Storage of Supplies and Equipment”, revised in November 2009, the policy indicated, “All invoices must be verified against the purchase order, properly assembled, noting returned goods, damages, shortages, etc., and forwarded to the business office for payment.” The policy also indicated, “A register of all supplies must be maintained by the Purchasing Agent and will include, as a minimum: a. Date; b. Name of company; c. Invoice number; d. Amount of purchase; e. Department ordering; f. Overage/shortage/damaged merchandise; and g. Others as necessary.” The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance for the alterations/renovations/construction in the facility from HCAI. In addition, the facility failed to notify the Department of Public Health within five days of the commencement of any construction/alterations to the skilled nursing facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.