Other·December 7, 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 [Reference: 2019 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 11/29/2021, an unannounced visit was made to the facility to investigate a complaint about physical environment. The facility installed new/replacement water heaters and conducted associated repairs (alterations) to the building’s plumbing system without being in substantial compliance from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development [OSHPD]). HCAI is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations. The following three facility water heater projects were not in substantial compliance with OSHPD/HCAI: 1. OSHPD/HCAI Non-Compliant Project #1 - During a concurrent record review and interview with, on 11/29/2021, at 11:09 a.m., MS stated the facility’s water heater replacement project documentation was reviewed. A letter from OSHPD, dated 10/1/2016, indicated building permit approved for “Water Heater Emergency Replacement” project with project number X160038-19-00. The letter also indicated that “construction must commence within one year from the date on the building permit or this permit will be voided unless an extension has been requested and approved prior to this date”. OSHPD building permit indicated project description as “Replace (1) Domestic Water Heater”. MS explained, water heaters related to this project were located near the facility’s activity room. The OSHPD’s Construction Advisory Report titled, “Water Heater Emergency Replacement”, dated 4/10/2017, project number “X160038-19-00”, the report indicated “Construction has not started to date” and “Construction, in accordance with the approved construction documents, shall commence within one year after obtaining the written approval of construction documents, or project approval shall become void in accordance with T24, CAC 7-129”. OSHPD’s project closure letter, dated 7/30/2018, indicated the construction project X160038-19-00 was closed due to inactivity. The document also indicated the following: a. “Previous attempts were made unsuccessfully by this Office to obtain all the necessary paperwork to comply with Title 24, of the California Code of Regulations (CCR).” b. “According to our records this construction project received plan approval more than one year ago and no extension has been granted. Therefore, your project has been closed due to inactivity.” On 11/29/2021, at 10:59 a.m., during an interview, the Administrator stated that per his conversation with a corporate representative, he was informed when the facility installed replacement water heaters, the Department was not notified because it is OSHPD/HCAI that notifies the Department. On 11/29/2021, at 11:27 a.m., during a concurrent observation and interview with MS, two water heaters were inside the water heater room near the activity room. One water heater had a visible manufacturing label indicating “AO Smith” with Model No. BTL-199 200, a Serial Number 1907113703991, Input Btu/Hr 199000, and a Build Date of 2/12/2019. MS stated both water heaters were replaced. 2. OSHPD/HCAI Non-Compliant Project #2 –On 10/13/2021, at 4:17 p.m., during an observation with MS, five water heaters were inside the water heater room near the basement/back parking area and had shiny (newer) copper piping connected to the water heaters. The water heaters observed were as follows: a. Water heater 1 was labeled “AO Smith” with Model No. BTL 154 104, Serial Number 1424M002537, Input Btu/Hr 154000, and a Build Date of 6/17/2014. b. Water heater 2 was labeled “AO Smith” with Model No. BTL 154 104, Serial Number 13O7M000125, Input Btu/Hr 154000, and a Build Date of 2/12/2013. c. Water heater 3 was labeled “Bradford White” with Model No. UCG100H2703N, Input Btu/Hr 270000, and Serial Number XA47136758. d. Water heater 4 was labeled “AO Smith” with Model No. BTL-257 200, Serial Number 1924115250573, Input Btu/Hr 275000, and a Build Date of 6/10/2019. e. Water heater 5 was labeled “AO Smith” with Model No. BTL-257 200, Serial Number 1649104157435, Input Btu/Hr 275000, and a Build Date of 12/2/2016. At the time of the observation, an interview with MS was conducted. MS stated the water heaters labeled 1 and 2 were supplying hot water to the kitchen and water heaters labeled 3, 4, and 5 were supplying hot water to the laundry room. All five water heaters were replaced due to water heater and the associated piping leaking. On 11/29/2021, at 11:09 a.m., an interview with MS and concurrent review of the water heater replacement project documentation was conducted. A letter from OSHPD, dated 10/3/2016, indicated building permit approved for “New Water Heater Project” with project number X160040-19-00. The letter indicated “construction must commence within one year from the date on the building permit or this permit will be voided unless an extension has been requested and approved prior to this date.” The OSHPD building permit indicated project description as “Replace the Kitchen & Laundry Room Water Heater.” MS explained, water heaters related to this project were located near the basement/back parking area and five water heaters were replaced. An OSHPD’s Construction Advisory Report titled, “New Water Heater Project,” dated 4/10/2017, project number “X160040-19-00,” the report indicated “Construction has not started to date” and “Construction, in accordance with the approved construction documents, shall commence within one year after obtaining the written approval of construction documents, or project approval shall become void in accordance with T24, CAC 7-129.” The OSHPD’s project closure letter, dated 7/30/2018, indicated the construction project X160040-19-00 was closed due to inactivity. The document indicated the following: a. “Previous attempts were made unsuccessfully by this Office to obtain all the necessary paperwork to comply with Title 24, of the California Code of Regulations (CCR).” b. “According to our records this construction project received plan approval more than one year ago and no extension has been granted. Therefore, your project has been closed due to inactivity.” 3. OSHPD/HCAI Non-Compliant Project #3 - On 10/13/2021, at 3:24 p.m., during an interview, MS stated the water heaters servicing Nursing Station 1 were both replaced because one of them was leaking and he informed the Administrator to replace it. On 10/13/2021, at 3:24 p.m., during a concurrent observation and interview with MS, two water heaters were inside the water heater room near the front parking area with shiny (newer) copper piping connected to the water heaters. Both water heaters were labeled “AO Smith”. One of two water heaters had a visible manufacturing label indicating Model No. BTL-199 200, a Serial Number 1705104853023, Input Btu/Hr 199000, and a Build Date of 2/2/2017. During a concurrent interview with the MS, the MS stated that both water heaters were replaced. MS explained the water heaters were temporarily installed on the right side of the water heater room and would be relocated to the left side of the water heater room where the wall anchorage was originally located. On 11/29/2021, at 11:09 a.m., an interview with MS and concurrent review of the water heater replacement project documentation was conducted. A letter from OSHPD, dated 10/3/2016, indicated building permit approved for “Water Heater Replacement” with project number X160039-19-00. The letter also indicated that “Construction must commence within one year from the date on the building permit or this permit will be voided unless an extension has been requested and approved prior to this date”. OSHPD building permit indicated project description as “Replace the existing Domestic Water Heater Tanks.” OSHPD’s Construction Advisory Report titled, “Water Heater Replacement,” dated 4/4/2019, project number “X160039-19-00,” indicated the following: a. On 5/4/2017, “current construction appears to include re-piping to accommodate relocation of existing water heaters and installation of new water heaters, installation of expansion tank, installation of new recirculating pumps, installation of tempering valve, and installation of temperature alarm.” “It does not appear that this project was reviewed to determine qualification as noted on FREER, Expedited Building Permit for Water Heater Replacement, Page 1.” b. On 4/4/2019, “reviewed IOR daily report dated 20170426 indicating existing 300K BTU unit was replaced with temporary 199K BTU unit,” “the work of construction, in accordance with approved construction documents, has been suspended for a period in excess of one year,” and “project approval appears void in accordance with T24, CAC 7-129.” c. On 4/4/2019, “temporary units appear in place to accommodate relocation of new units. Relocation of units is needed to accommodate anchorage of a freestanding unit to be anchored to a wall. This does not appear to be in accordance with approved construction documents as required by T24, CAC 7-143” and “Repiping includes installation of a new mixing valve. This does not appear part of the approved construction documents as required by T24, CAC 7-143.” d. On 4/4/2019, “anchorage of units currently in place appear cantilevered via unistrut from the wall. This does not appear in place per approved construction documents as required by T24, CAC 7-143.” A review of facility’s Inspector of Record (IOR)’s report, dated 4/14/2019, indicated the following: a. “Onsite to inspect work that was completed and installed without inspection.” b. “Existing 300,000 BTY and 199,000 BTU (tank was not operable) were replaced with two temporary 199,000 BTU water heaters. Contractor and PM state the intention is to install new piping, new mixing valve and relocate these two temp water heaters to permanent locations once unistrut and piping installed on wall.” c. “Water heaters are strapped to wall; contractor could not identify anchorage to concrete. Appeared to be 3/8” bolts, contractor stated they were not torqued and did not have a torque on site then.” d. “Contractor has connected new vents for both temporary water heaters to existing penetrations through roof.” e. “Gas line is on wood blocking, however blocking not secured to floor. Piping not properly supported (existing and temporary). While on site witnessed joints were not leaking at working pressure in excess of 15 minutes, however code stated this is to be done prior to use.” According to OSHPD’s project closure letter, dated 8/23/2021, indicated that construction project X160039-19-00 was closed without compliance with the California Building Standards Code. The document indicated the following: a. “Our records show that construction on this project has been suspended or abandoned for more than one year or unauthorized, unapproved construction and we have not received an acceptable plan of action for the completion of the remaining work in compliance with the California Building Standards Code. Previous attempts were made unsuccessfully by this Office to obtain an acceptable plan of action and to facilitate completion of the project in order to close the project in compliance with Title 24, of the California Code of Regulations (CCR).” b. “This construction project is closed without benefit of a final State agency inspection of the work as required by Title 24, Part 1, Section 7-155(a). Hazardous conditions related to structural safety, fire and life safety and public health may exist as a result of the suspension or abandonment of this project or as a result of unauthorized, unapproved construction.” A review of the facility’s policies and procedures titled, “Maintenance Services”, undated, the document stipulated that the “maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe manner at all times”. The following functions are performed by maintenance: 1. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. 2. Maintaining the building in good repair and free from hazards. 3. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The facility installed new/replacement water heaters and conducted associated repairs (alterations) to the building’s plumbing system without being in substantial compliance from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development [OSHPD]). HCAI is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations. The above violations had a direct relationship to the health, safety, and security of all the residents occupying the facility.