Health inspection·July 21, 2023

§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 1, 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. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. K111- Building Rehabilitation, Repair, Renovation, Modification or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.3, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 On 6/7/23, at 8:45 a.m., a Life Safety Code (LSC) survey was conducted for the facility’s annual recertification. The facility failed to obtain the necessary permits/construction sign-off final approval from the Department of Healthcare Access and Information (HCAI, which is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare buildings to comply with State codes) and failed to notify the Department within five days of commencement for the installation/replacement of for the installation/replacement of two temporary electrical generators. This deficient practice has the potential for fire related accidents and/or the inability of the generators to properly function due to the incorrect/unregulated installation, which directly affects 315 of 315 residents with varying levels of medical and mental conditions. On 6/7/23, between 8:45 am and 2:30 pm, during the LSC observational tour, the facility had two temporary generators; one located near the detached laundry room, and a second located near the Manor building. On 6/8/23, at 8:05 am, during a review of the facility’s HCAI (the Department of Health Care Access and Information, which is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare buildings to comply with State codes) field report, dated 7/6/22, it was indicated that the facility had two unpermitted temporary generators, which is a violation of the California Code of Regulations, Title 24, Section 7-128 specifics that construction or alterations of any health facility performed without the benefit of review, permit, and/or observation by the (HCAI) Office shall be subject to examination by the Office to assess relevant code compliance. This field report also stated, “This is a Fire and Life Safety hazard that requires prompt resolution.” On 6/8/23, at 1:30 pm, during a review of the facility's fire inspection reports and documentation, there was no documentation or HCAI permits to indicate that the facility received approval for the use the two temporary generators. During review of the generator service report, dated 4/9/23, it was indicated that the two temporary generators received regular servicing. On 6/8/23, at 3:10 pm, during an interview, the administrator stated that she was not aware that the facility has not obtained permits for the temporary generators and thought they were permitted. Furthermore, she was not aware if the installation of these generators was reported to this department. The facility failed to obtain the necessary permits/construction sign-off final approval from HCAI and failed to notify the Department within five days of commencement for the installation/replacement of for the installation/replacement of two temporary electrical generators. The above violations had a direct or immediate relationship to the health, safety, or security of all patients.