Other·January 20, 2022

§72601 (a). Alterations to Existing Buildings or New Construction. 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. The department received a complaint on 12/07/2021 regarding an unapproved generator on a trailer at the facility. A joint unannounced complaint investigation was conducted at the facility on 12/08/2021 with Health Facilities Inspection Division (HFID) and the Department of Health Care Access and Information [HCAI formerly known as the Office of Statewide Health Planning and Development (OSHPD)]. The facility failed to obtain a required building permit and attain construction approval from the Department of Health Care Access and Information [(HCAI) is the State agency that reviews and approves plans for construction, repairs, renovations and alterations made to healthcare facilities to comply with State Building Codes] for the facility’s emergency generator alterations, including a temporary emergency generator on a trailer installation, a new generator, and construction of an emergency generator roofing enclosure. During the facility tour with HCAI Fire Marshal 1, HCAI Regional Fire Marshal 2, the ADM, and MS 1, the evaluator observed a temporary emergency generator, on a trailer, with its wheels parked within the employee parking lot. During a concurrent interview with HCAI Fire Marshal 1, he stated that prior to the installation of the temporary emergency generator, the facility was using an unpermitted generator onsite. HCAI Fire Marshal 1 stated that on 7/2/2014, the facility was “cited by HCAI for having an unpermitted generator that failed.” HCAI Fire Marshal 1 also stated that the location of the temporary emergency generator was not approved due its proximity to the facility property line. During a record review of the HCAI permit documentation conducted on 12/08/2021 at 1:15 p.m., it indicated that the facility applied for a permit for the temporary generator (trailer generator/project number: S170142-19-00). This permit specifically stated that the emergency generator “shall be installed and operated for 180 days.” The paperwork also indicated that that “zero documentation was submitted, and zero workflow was recorded.” The project was closed as “inactive” on 5/02/2017. During a record review of the HCAI permit documentation conducted on 12/08/2021 at 1:20 p.m., it indicated that the facility applied for a permit for the replacement of the main backup generator (project number: S163155-19-00). It also indicated that this project was closed due to “zero documentation submitted, and zero workflow recorded.” The project was closed as “inactive” on 2/07/2017. During an interview on 12/08/2021 at 1:15p.m., HCAI Fire Marshal 1 stated that the facility applied for a temporary generator permit in May 2017. The project number was S170619-19-00. The project was approved on 5/12/2017, however it was closed due to non-compliance. HCAI Fire Marshal 1 stated that this project permit was reopened again by HCAI and approved with comments on 7/15/2019. The facility had yet to provide any answers and/or documentation to the comments as of 12/8/2021. The above HCAI project (S170619-19-00) details indicate the following: (1) Disconnect existing non-conforming emergency generator. (2) Provide temporary diesel emergency generator and connect to the existing emergency power feeder into the building. (3) Provide cabling and physical protection for emergency cabling. (4) Provide structural supports as needed for temporary emergency generator. (5) The temporary generator will remain on site up to 180 days while a permanent generator is planned and installed. According to the Fire and Life Safety Construction Advisory Report from HCAI, dated 12/8/21, and authored by HCAI Fire Marshal 1, the following non-compliant HCAI issues were noted regarding the 1) New Emergency Generator & Enclosure (Project #H191684-19-00, 2) Emergency Generator Enclosure (Project #G191740-19-00 and the 3) Temporary Emergency Generator (Project #S191046- 19-00): 1) Project # H191684-19-00: The plans have not been approved, a work permit has not been applied for and work has not started. The project is in violation of California Administrative Code Section 7-129(a). 2) Project #G191740-19-00: The plans have not been approved, a permit has not been applied for and work has not started. The project is in violation of California Administrative Code Section 7-129(a). 3) Project #S191046-19-00/Trailer Generator): The plans were approved; a permit has not been applied for and the work was started. The generator was placed and connected to existing generator connections. The temporary generator has not been installed in compliance with plans. This is in violation of California Administrative Code, Section 7-143. There is no ground at the generator. This is in violation of California Electrical Code, Section 25.20. During an interview with the administrator (ADM) and MS 1 on 12/08/2021 at 1:06 p.m., the ADM stated that he was aware of the temporary emergency generator (on a trailer) and was having issues with the corporate office giving financial approval to complete the projects. The ADM stated that he had only been with the facility for approximately three months. The ADM also stated that after the facility was surveyed by the Centers for Medicare and Medicaid Services (CMS) on 11/02/2021, he contacted the corporate offices regarding the temporary emergency generator (on a trailer) being removed and replaced with a permanent installation. He also stated that the corporate project managers would be working with HCAI to get the appropriate permits to complete the project. He also stated that this generator project has been kept unfinished for too long and should have been completed by 2021. The facility failed to obtain a required building permit and attain construction approval from the Department of Health Care Access and Information [(HCAI) is the State agency that reviews and approves plans for construction, repairs, renovations and alterations made to healthcare facilities to comply with State Building Codes] for the facility’s emergency generator alterations, including a temporary emergency generator on a trailer installation, a new generator, and construction of an emergency generator roofing enclosure.