Health inspection·December 18, 2025

22 CCR §72541. Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. § 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/1/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding Physical Environment. The facility failed to implement its policy and procedure (P&P) titled “Unusual Occurrence Reporting” by failing to report to the State Survey Agency (SSA) an inoperable emergency generator within 24 hours of identifying the issue and by failing to submit a written report to the SSA detailing the incident and the corrective actions taken by the facility. On 10/27/2025, the facility’s permanent emergency generator, which is programmed to automatically perform a weekly test failed to start during both automatic and manual attempts on 10/27/2025. As a result, the Department was unable to conduct a timely onsite inspection to ensure the safety of residents including the potential impact of a power outage on critical life-support equipment (medical devices that sustain or replace vital bodily functions), fire protection systems (set of devices and equipment designed to detect, control, and extinguish fires), emergency lighting (lighting that activates during power failure to allow safe evacuation), and other essential systems, and to verify that the inoperable emergency generator incident was promptly investigated and addressed by the facility. A review of the facility’s Work Order Form dated 11/7/2025, requested by the Maintenance Supervisor (MS), signed and approved by the Administrator (ADM), indicated the issue as a priority problem – emergency, requiring immediate repair. The Work Order Form indicated that since 10/27/2025, a component of the emergency generator was not functioning, requiring immediate corrective action such as installing a temporary generator to maintain the facility’s emergency power system. A review of the Service Report dated 11/7/2025 indicated that the facility’s existing emergency generator was experiencing starting issues, and the cause of the failure was unknown. During an interview on 12/2/2025 at 10:51 a.m., with the MS, the MS stated that during the facility’s weekly check of the permanent emergency generator on 10/27/2025, the permanent emergency generator failed to start. The MS further stated that due to the facility’s permanent emergency generator being inoperable, he (MS) immediately reported the issue to the ADM. During an interview on 12/2/2025 at 4:30 p.m., with the Director of Nursing (DON), the DON stated that she (DON) was aware the facility’s permanent emergency generator was inoperable on the morning of 10/28/2025, during the facility’s stand-up meeting. The DON stated that the generator’s inoperability constitutes an unusual occurrence and should have been reported to the SSA in accordance with the facility policy and regulatory requirements. The DON further stated that it is the responsibility of the ADM to report unusual occurrences. During an interview on 12/2/2025 at 4:51 p.m., with the ADM, the ADM stated that any unusual occurrence must be reported to the SSA within 24 hours of identifying the issue or incident. The ADM stated that the MS reported the permanent emergency generator was not operational on 10/27/2025. The ADM continued to state that she (ADM) submitted the unusual occurrence report related to the emergency generator on 11/14/2025, which was 18 days after the issue was initially identified. When asked why the ADM did not report the unusual occurrence within 24 hours, the ADM stated that she (ADM) was instructed by the facility’s Corporate Consultant not to submit the report to the SSA until directed to do so. The ADM stated that she (ADM) should have reported the permanent emergency generator inoperability to the SSA in accordance with regulatory requirements and the facility’s policy on unusual occurrences. The ADM further stated that she did not have a detailed written report of the unusual occurrence to provide to the SSA, and when asked why the report was not available, the ADM did not provide a response. During a review of the facility’s P&P titled “Unusual Occurrence Reporting”, last reviewed on 1/8/2025, indicated “as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Our facility will report the following events to appropriate agencies: f. Inoperable emergency systems, equipment or resident call systems, which if not corrected could readily become life-threatening; h. other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.” The facility failed to implement its P&P titled “Unusual Occurrence Reporting” by failing to report to the SSA an inoperable emergency generator within 24 hours of identifying the issue and by failing to submit a written report to the SSA detailing the incident and the corrective actions taken by the facility. On 10/27/2025, the facility’s permanent emergency generator, which is programmed to automatically perform a weekly test failed to start during both automatic and manual attempts on 10/27/2025. As a result, the Department was unable to conduct a timely onsite inspection to ensure the safety of residents including the potential impact of a power outage on critical life-support equipment, fire protection systems, emergency lighting, and other essential systems, and to verify that the inoperable emergency generator incident was promptly investigated and addressed by the facility. The above violation had a direct or immediate relationship to the health, safety, or security of the residents in the facility.