Health inspection·December 8, 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. 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 11/20/2025 at 8:30 AM, CDPH made an unannounced visit to the facility to investigate a complaint regarding the physical environment. The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from the 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) for the following: 1) Replacement of flooring and wall base molding (trim pieces installed at the joint where the wall meets the floor), 2) Replacement of exterior window and metal windows replaced with vinyl windows, 3) Alteration to wall finish without protective rail present, 4) Alterations to Nurse Station 2, 5) Demolition of exterior wall and the removal of the stucco (plaster used to coat wall surfaces) and studs (vertical beams that make up the frame of the wall), 6) Removal of all finishes (walls and flooring) in 30 patient rooms, 7) Removal of all finishes (walls and flooring) and plumbing fixtures in 30 patient bathrooms, 8) Patching and painting of stucco on exterior face of facility around existing windows that disturbed the entire vertical elevation (from existing grade to roof line), 9) Installation of wall-mounted water fountain that does not appear to be compliant with requirements of the Americans with Disabilities Act (ADA), 10) Placement of construction equipment and storage containers in the parking lot that take up required parking spaces, 11) Placement of contractor lay-down space (staging area in a construction site for storing materials, tools, and equipment) with construction equipment and no construction barrier evident in the courtyard, and 12) Conversion of resident room into an office with installation of cubicle half-walls. The facility also failed to notify the Department within five days of the commencement of any construction, remodeling, or alterations to the facility. As a result, 56 residents were placed at risk of accidents from unauthorized equipment installation, alterations, renovations, and constructions. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents. 1) HCAI Non-Compliant Work 1 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s Compliance Officer (CO), the report indicated, “Flooring replacement (sheet vinyl replaced by sheet vinyl) in southern corridor. Rubber base replaced with wood base.” During an interview on 11/20/2025 at 9:30 AM with the Administrator (ADM), the ADM stated, “We changed the dark wood color [flooring] to lighter grayish color mainly for cosmetics. It was between 10/20/2025 to 11/7/2025. Alteration was done near Resident Room 17 all the way around to Room 46.” During a concurrent observation and interview on 11/20/2025 at 9:40 AM with the ADM in the corridor between Resident Room 17 to Resident Room 46, light grey flooring was installed. The ADM stated the approximate square footage of the light grey flooring was eight feet (ft) by 48 ft. During an interview on 11/20/2025 at 9:43 AM with the ADM, the ADM stated the installation of the wood wall base molding was conducted between 10/20/2025 to 11/7/2025. During an observation on 11/20/2025 at 9:56 AM with the ADM in the corridor between Resident Room 17 to Resident Room 37, there was wood wall base molding installed between the floor and wall. During a concurrent observation and interview on 11/20/2025 at 11 AM with the ADM in the dining room, wood wall base molding was installed between the floor and wall. The ADM stated the wood wall base molding was approximately 20 ft by 27 ft. 2) HCAI Non-Compliant Work 2 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Exterior window replacement on east elevation. Metal windows replaced with vinyl windows.” During a concurrent observation and interview on 11/20/2025 at 9:56 AM with the Maintenance Supervisor (MS) in the parking lot, new vinyl windows were installed for two rooms facing the parking lot. The MS stated the new windows were installed in Resident Room 45 and the employee breakroom. During a concurrent observation and interview on 11/20/2025 at 10 AM with the MS at the exterior walkway on the south side of the building, new vinyl windows were installed on the south and west facing exterior walls of the building. The MS stated the new windows were installed in Resident Room 17, 18, 19, 21, 22, 23, 26, 27, 28, 29, 31, 33, 35, 29, 41, 42, 43, and 44. The MS stated the work began about three weeks ago, and the work is completed. During a concurrent observation and interview on 11/20/2025 at 10:14 AM with the MS in the middle courtyard, new vinyl windows were installed at four windows facing the courtyard. The MS stated the new windows were installed in Resident Room 34, 36, 38, and 40. The MS stated the rooms used to have metal windows. During an interview on 11/20/2025 at 11:06 AM with the ADM, the ADM stated the windows on the south facing walls needed to be repaired or replaced due to stucco damage. The ADM stated the windows for the rooms facing the courtyard also needed to be repaired or replaced; they were metal windows, and the rooms did not have access to the courtyard, unlike the rooms on the opposite side. 3) HCAI Non-Compliant Work 3 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Wall finishing with paint and wood wainscotting (decorative wall paneling) in southernmost corridor. No protective rail present.” During a concurrent observation and interview on 11/20/2025 at 10:04 AM with the ADM in the corridor between Resident Room 22 to Resident Room 46, there were no handrails installed on the walls. The ADM stated, “From Room 22 to Room 46, the wainscotting was added for decoration, but HCAI said we’re still required to have handrail and cove base in the hall.” During a concurrent observation and interview on 11/20/2025 at 11:04 AM with the ADM in the dining room, wainscotting was installed on the walls. The ADM stated the wainscotting was approximately 20 ft by 27 ft. 4) HCAI Non-Compliant Work 4 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Enclosed Nurse Station #2…Full height wall with various sized windows built on top of transaction cap. Locked doors with incorrect egress direction installed at north and south demising walls.” During an interview on 11/20/2025 at 10:09 AM with the ADM, the ADM stated they painted and added the wainscotting to the nursing station around 10/20/2025 to 11/7/2025, to improve the cosmetics. During an interview on 11/20/2025 at 10:12 AM with the ADM, the ADM stated the contractors replaced the nursing station doors because there was some damage to the original doors. During an observation on 11/20/2025 at 10:15 AM in Nursing Station 2 with the ADM, the nursing station was enclosed by full height walls with windows and both entrance doors swung inward against egress. 5) HCAI Non-Compliant Work 5 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Demolition of exterior north wall for the purpose of installing either a new door or new window. Stucco and studs appear to be removed.” During a concurrent observation and interview on 11/20/2025 at 9:56 AM with the MS in the parking lot, an exterior wall was covered with plywood. The MS stated the wall was removed about three weeks prior and the plywood is a boarded-up window in Resident Room 46. During an interview on 11/20/2025 at 10:57 AM with the ADM, the ADM stated the window in Resident Room 46 was removed on 11/5/2025, two days before HCAI came to the facility. 6) HCAI Non-Compliant Work 6 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Removal of all finishes (walls, flooring) in approximately 12 patient rooms in northeast section of facility.” During a concurrent observation and interview on 11/20/2025 at 10:28 AM with the ADM along the resident room corridor, 30 resident rooms had bathroom floor tiles that were different from the other resident rooms. The ADM stated, “30 patient rooms, from Room 17 to Room 46, have had bathroom floor and base coving replaced with decorative tile…The work was done between 10/20/2025 to 11/7/2025.” 7) HCAI Non-Compliant Work 7 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Removal of all finishes (walls, flooring) and plumbing fixtures in approximately 12 patient bathrooms in northeast section of facility.” During a concurrent observation and interview on 11/20/2025 at 10:35 AM with the ADM along the resident room corridor, 30 resident rooms had bathroom floor tiles that had work done. The ADM stated, “The toilet was only temporarily removed for tile work. When contractors were prepping for the tile work, the plumbing hole was left open and the HCAI said that it should be covered to prevent debris from entering.” 8) HCAI Non-Compliant Work 8 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Patched and painted stucco on exterior west face of facility around 10 existing windows: Entire vertical elevation (from existing grade to roof/eave line) was disturbed as part of the exterior stucco patching or replacement.” During a concurrent observation and interview on 11/20/2025 at 9:47 AM with the MS at the front of the building, the entire north facing wall was painted from existing grade to roofline. The front of the building was painted white, and the old paint was dark tan in color. The MS stated, “We used to have two different colors of paint at the front of the building. The wall above and below the windows were a different color from the rest of the building. All the water from the sprinklers hit the wall and damaged the stucco under the windows. There were cracks in the stucco throughout the wall. They repaired the cracks and water damage on the walls and repaired the holes where signs were anchored to the roof. They started painting and patching about three weeks ago.” 9) HCAI Non-Compliant Work 9 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Wall mounted water fountain which does not appear to be ADA-compliant (alcove recess is not wide enough for wheelchair and plumbing is in conflict with toe space).” During an observation on 11/20/2025 at 10:39 AM with the ADM by Nursing Station 2, there was a drinking water fountain with a recessed alcove measuring 81 inches in height, 23 inches in width, and 20 inches in depth. During an interview on 11/20/2025 at 10:45 AM with the ADM, the ADM stated, “The water fountain was already there, but we upgraded to a newer one with a sensor and water refill station…I’m not sure if the pipes/connections are the same. The water fountain was upgraded sometime between 10/20/2025 to 11/7/2025.” 10) HCAI Non-Compliant Work 10 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “Construction equipment and storage containers in the north parking lot, taking up required parking spaces.” During a concurrent observation and interview on 11/20/2025 at 9:32 AM with the MS in the parking lot, construction material, equipment, and storage containers were stored throughout the parking lot. The MS stated the construction material, equipment, and storage containers were by the old trash area and in front of windows belonging to the employee break room, Resident Room 45, Resident Room 46, and the southeast corridor. The MS stated the affected areas measured 24 ft by 25 ft and 24 ft by 20 ft (approximately 1080 square ft total). The MS stated five parking spaces were blocked by storage containers. During an interview on 11/20/2025 at 11:04 AM with the ADM, the ADM stated two of the storage containers were already in the parking lot on 11/14/2025 and the other two storage containers were brought in on 11/18/2025. 11) HCAI Non-Compliant Work 11 – During a review of HCAI’s Fire and Life Safety Report – Field Visit Report, dated 11/7/2025, authored by HCAI’s CO, the report indicated, “There is contractor lay-down space, with unidentified lumber, in the facility courtyard, with no construction barrier present.” During a concurrent observation and interview on 11/20/25 at 10:14 AM with the MS in the courtyard, construction material, including rebar (steel bars used for reinforcement of structures) and ladders, were stored throughout the courtyard and no construction barriers were present. The MS stated that residents have access to this area from the dining room. During an interview on 11/20/2025 at 2:35 PM with the ADM, the ADM stated the construction materials were placed in the courtyard 30 to 45 days prior by the construction crew. 12) During an observation on 11/20/2025 at 10:21 AM with the MS in the courtyard by the window to Resident Room 20, construction equipment was stored and half-walls were constructed inside Resident Room 20. During a concurrent observation and interview on 11/20/2025 at 11:10 AM with the ADM at the door to Resident Room 20, the ADM was unable to access the room through the locked door. The ADM stated that only the contractors have the key to the room. The ADM stated this room was formerly Resident Room 20 which was being converted into an office space with cubicles, but it was not going to pan out because it would be a much bigger project than expected. During an interview on 11/20/2025 at 11:15 AM with the ADM in the courtyard, the ADM stated that Resident Room 20 has half-walls inside because they wanted to make it into an office space with cubicles, but they discontinued the work because the financials did not work out. During an interview on 11/21/2025 at 9:15 AM with the ADM, the ADM stated they were converting Resident Room 20 to create additional cubicle spaces for use by office staff. The ADM stated the work was conducted by the facility’s maintenance crew between 10/20/2025 to 11/7/2025. During a concurrent observation and interview on 11/21/2025 at 9:35 AM with the ADM in Resident Room 20, the room had partial cubicle half-walls and various office supplies, including chairs and cabinets. The ADM stated, “We halted the work on Resident Room 20 conversion. Our plan is to revert it back to its original state.” During an interview on 11/20/2025 at 1:28 PM with the ADM, the ADM stated they are aware of the facility’s requirement to obtain approval from HCAI f