Health inspection·October 26, 2021

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 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 8/3/2021, an unannounced visit was conducted at the facility to investigate a facility reported incident about the physical environment. The facility failed to obtain a required building permit and attain construction approval from the Office of Statewide Health Planning & 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 repair/replacement of the facility’s domestic water main and failed to notify the Department (State Agency Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility. A review of the facility’s report of Unusual Occurrence, dated 8/2/2021, indicated on 8/1/2021 at 7 p.m., a staff member identified water leaking from the surface of the concrete located at the exterior south side of the facility. Facility maintenance personnel identified the source of the leak being the main water line and necessitated the water being shut off on 8/1/2021, starting at 7:24 p.m. On 8/3/2021, at 3:11 p.m., during an interview, Maintenance Supervisor (MS) stated a plumber was called for the leaking pipe and arrived at the facility Monday morning (8/2/2021) to make repairs. MS stated the issue was resolved as of “this morning” (8/3/2021) and the water was restored to the facility at approximately 11:30 a.m. MS explained, there was no OSHPD permit obtained for the plumbing work (construction) due to the nature of the emergency. On 8/3/2021, at 2:24 p.m., during a concurrent observation and interview with the Administrator (ADM), new copper pipes were being installed next to a sign indicating “WATER SHUT-OFF MAIN VALVE” at the exterior of the facility. There were concrete blocks on the ground and parts of concrete flooring had been removed. ADM stated plumbers had replaced elbow pipes to the building and replaced approximately 12 feet of galvanized pipe to copper pipes along the main water line. On 8/3/2021, at 4:25 p.m., during an interview, ADM confirmed OSHPD was not notified of the repair/replacement of the main water line and a permit/approval was not obtained prior to the start of construction. A review of an OSHPD’s document titled, “FREER Manual for General Acute Care Hospitals, Psychiatric Hospitals, Skilled Nursing Facilities and Intermediate Care Facilities”, revised on 10/2013, mandates that construction documents and application for plan review must be submitted prior to the start of construction, and a building permit must be issued for the project. A review of the Construction Advisory Report from OSHPD, dated 8/10/2021, indicated that in addition to application for plan review, construction documents, and required application for building permit being required to be submitted by the facility, a sampling of water for bacteriological examination/testing was recommended for the facility to be in full compliance. Additional repairs or corrections may be required if the emergency repairs do not comply with applicable code or approved plans. On 9/13/2021, at 12:38 p.m., during an interview, ADM confirmed the facility did not notify the Department of the repair/replacement of the main water line prior to the start of construction. ADM asserted that the Department was notified of the unusual occurrence which would imply “work that will be done.” The facility failed to obtain a required building permit and attain construction approval from OSHPD for the repair/replacement of the facility’s domestic water main and failed to notify the Department within five days of the commencement of any construction/alterations to the skilled nursing facility. The above violations had a direct relationship to the health, safety, and security of the residents occupying the facility.