Health inspection·December 18, 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 12/3/2025 at 11:20 a.m., CDPH made an unannounced visit to the facility to investigate a FRI regarding the physical environment. 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) and installation of a temporary annunciator (device that indicates the emergency generator’s operating status) in the Nurse Station with conduits (pipe or channel to protect electrical wiring) running through the attic and over the roof. As a result, 140 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 observation on 12/3/2025 at 11:50 a.m. with the Maintenance Supervisor (MS) at Nurse Station 1, a second annunciator with the label “KOHLER Power Systems” was installed on the wall adjacent to the first annunciator with the label “PowerCommand”. A metal pipe connected to the second annunciator protruded through the ceiling and the penetration was sealed by a firestop (material installed to seal gaps or openings to prevent fire and smoke from spreading). The indicator light (visual warning light indicating the condition or status of the annunciator) on the second annunciator was activated, while the indicator light for the first annunciator was not. During an interview on 12/3/2025 at 11:52 a.m. with the MS at Nurse Station 1, the MS stated the second annunciator is connected to the temporary emergency generator. During an interview on 12/3/2025 at 11:54 a.m. with the MS in the Maintenance Office, the MS stated the permanent emergency generator, which is programmed to automatically run a weekly test, failed to start during both automatic and manual attempts on 10/27/2025. The MS stated they reported the issue to the facility consultant on 10/27/2025. The MS stated the generator company identified a software issue (flaw, error, or defect in code causing unexpected behavior, crashes, or incorrect results) on 10/29/2025, but the generator company was unable to fix the permanent emergency generator at that time. The MS stated the generator company informed the facility that the permanent emergency generator was fixed on 11/4/2025, but it again failed to start during a test conducted by the MS on 11/5/2025. During an interview on 12/3/2025 at 12:01 p.m. with the MS in the Maintenance Office, the MS stated that both the generator company and the facility consultant determined a replacement part was needed for the permanent emergency generator, and that a temporary emergency generator would be required until repairs were completed. The MS stated the temporary emergency generator arrived and was installed by the facility’s contractor on 11/7/2025. The MS stated a second annunciator was installed for the temporary emergency generator because the first one cannot be used while the permanent emergency generator is inoperable. The MS stated they did not know the status of the HCAI Emergency Authorization to Proceed (EAP) project that was created by the facility on 11/13/2025. During an observation on 12/3/2025 at 12:38 p.m. with the MS in the emergency generator area, the facility's permanent emergency generator control panel displayed no information on the screen. During an observation on 12/3/2025 at 12:39 p.m. with the MS in the emergency generator ATS area, pipes protected by ground-level cable protection connected the ATS to the temporary emergency generator. During a concurrent observation and interview on 12/3/2025 at 12:41 p.m. with the MS in the emergency generator area, the temporary emergency generator was inside a fenced enclosure, secured to a pole, and surrounded by traffic cones and water-filled traffic barriers. The temporary emergency generator, labeled "Kohler", had a grey pipe extending to the floor, wall, and ceiling of the emergency generator ATS area. The MS stated this grey pipe connects to the secondary annunciator in Nurse Station 1. During an interview on 12/3/2025 at 12:43 p.m. with the MS in the emergency generator area, the MS stated the secondary annunciator would be removed along with the temporary emergency generator once the permanent emergency generator is repaired, since the secondary annunciator is part of the temporary set-up. During an interview on 12/3/2025 at 2:01 p.m. with the Administrator (ADM) in the Social Services Office, the ADM stated an HCAI project was submitted, but they could not provide further details since communication with HCAI is managed by the facility consultant. The ADM stated they did not know if HCAI was aware of the second annunciator installation or any related open projects. During an interview on 12/3/2025 at 2:26 p.m. with the ADM in the Social Services Office, the ADM stated that it is important to let HCAI be aware of changes or installations in the facility because it relates to patient safety. During an interview on 12/4/2025 at 1:56 p.m. with the ADM in the Administrator's Office, the ADM stated they have not received an update from the facility consultant regarding the HCAI project. The ADM stated the last update came from an e-mail received on 12/3/2025 from the facility consultant, which mentioned that one consultant had already provided the necessary information to HCAI, and another consultant indicated that an architect was working on drawings to be submitted to HCAI. During a concurrent interview and record review on 12/4/2025 at 2:58 p.m. with the ADM in the Administrator's Office, a letter from HCAI to the facility, dated 11/26/2025, was reviewed. The letter indicated there had been no response from the facility since 11/17/2025 for the EAP project to install a temporary emergency generator that was created on 11/13/2025. The letter indicated the necessary information and documentation required from the facility for EAP approval. The ADM stated the facility has not received an emergency authorization letter from HCAI due to the outstanding information and documents. During an interview on 12/4/2025 at 3:10 p.m. with the MS in the Administrator’s Office, the MS stated there has been no update on the repair of the permanent emergency generator, and the facility is still waiting for the necessary parts. During an interview on 12/4/2025 at 3:16 p.m. with the MS in the Administrator’s Office, the MS stated the facility consultant handles all generator-related matters and serves as the point of contact on generator issues, service requirements, and maintenance schedules. During an interview on 12/4/2025 at 3:38 p.m. with the ADM in the Administrator’s Office, the ADM stated the facility is still waiting for the permanent emergency generator to be repaired. During an interview on 12/4/2025 at 3:49 p.m. with the MS and ADM in the Administrator's Office, the MS stated that obtaining authorization from HCAI is important because it ensures the temporary emergency generator is installed correctly, reliable, and has been properly tested to confirm it will work during an emergency. During a review of the service report for the installation of the temporary emergency generator, dated 11/7/2025, the service report indicated the permanent emergency generator had starting issues. The service report also indicated a temporary emergency generator and an annunciator were installed and connected. The service report also indicated that a temporary emergency generator was connected to the facility's existing ATS, the annunciator was connected at the Nurse Station and deemed operational, a building load test was performed, the temporary emergency generator started within 10 seconds, and the emergency power source was restored. The service report indicated fencing and protective K-Rails (portable concrete or plastic barriers) were installed. The service report indicated, "HCAI project pending.” During a review of the facility’s Inspector of Record (IOR, an independent inspector certified by HCAI that is responsible for verifying that all construction work complies with approved plans and applicable codes) report titled, “Daily Inspection Report,” dated 11/12/2025, the report indicated, “IOR was notified that the existing emergency generator was failing, and that a temporary emergency generator was delivered. Cable connections from the generator to the existing ATS were made by electricians…A new annunciator installed in the nurse station was observed, along with new conduit runs through the attic and over the roof for connection to the new generator. Ground-level cable installation is not complete and in progress. K-rail protection for the generator is installed with required water in all units. A test of the generator start-time was not possible this date, due to the presence of CDPH performing facility reviews. Construction document preparation is in progress per the DPOR [Design Professional on Record, individual who is registered or licensed to practice their respective design profession, and who is responsible for a project, or a portion of a project’s design and/or engineering], with HCAI review & approval to follow.” During a review of an e-mail from HCAI to the facility with subject line, “HCAI project E251977-19-00 Field Review Requested,” dated 11/13/2025, the e-mail indicated the facility had submitted a project to HCAI. The e-mail indicated the facility must contact the HCAI field staff to schedule the field review. During a review of a letter from HCAI to the facility, dated 11/26/2025, the letter indicated there had been no response from the facility since 11/17/2025 for the EAP project to install a temporary emergency generator that was created on 11/13/2025. The letter indicated the necessary information and documentation required from the facility for EAP approval. During a review of the facility's policy titled, "Maintenance Service Policy," dated 12/2009, the policy indicated, “The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.” The policy also indicated, “Functions of maintenance personnel include, but are not limited to…maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines...maintaining the fire alarm system and emergency generator system in good working order." During a review of the facility's policy titled, "Emergency Generator or Alternate Energy Source Policy," dated 4/2019, the policy indicated, "If there is a disruption in the normal power supply, alternate source of energy will be used to maintain subsistence needs.” The policy also indicated, “Some examples of alternate sources of energy may include portable and mobile generators, a permanent generator, or a contracted service that supplies generators." The policy also indicated, "Any alternate energy source is used in accordance with local and state laws, manufacturer instructions and any applicable Life Safety Code requirements." 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, including connections to the facility’s ATS and installation of a temporary annunciator in the Nurse Station with conduits running through the attic and over the roof. As a result, 140 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.