Other·March 13, 2023

72601. 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. On February 6, 2023, at 12:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding physical environment. The facility failed to obtain the necessary permits/construction sign-off final approval from the Department of Healthcare Access and Information ([HCAI] previously known as the Office of Statewide Health Planning and Development [OSHPD]) for the unpermitted replacement/repair of a water supply pipe for the facility’s fire sprinkler system. This deficient practice had the potential to result in an unapproved/permitted sprinkler system that may not properly function due to lack of regulatory inspections and oversight. This may increase the risk of fire damage and injuries in a fire emergency. The facility has a bed capacity of 59 beds, which may have residents with varying levels of medical and mental conditions. On February 4, 2023, this department was notified by the facility that the fire sprinkler system was turned off due to a leak in the water supply pipe for the sprinkler system. On February 4, 2023, at 12:30 pm, a complaint investigation was initiated regarding the facility's broken water sprinkler pipe. The director of nursing (DON) was informed of the complaint visit On February 4, 2023, at 12:40 pm, during an interview, the DON stated that on the morning of February 3, 2023, the pipe to the facility’s sprinkler system broke and water was coming out of the ground at the rear of the premises, on the south-east corner, close to the fence. The broken pipe disabled the sprinkler system and the facility staff turned off the water, at the riser (a riser is a water valve that receives water from the city’s water line, dedicated to the facility’s sprinkler system.). The facility immediately notified the local fire department. Plumbers were called that same day and they assessed the problem but could not fix the problem because they cannot work on the sprinkler system. The facility called a sprinkler system company who could not come out until the next day. Soon after, the facility implemented its fire watch procedure. On the morning of February 4, 2023, a sprinkler system company came out and assessed the problem. They determined that the 5-inch water supply pipe was damaged by nearby roots, causing water to leak out on to the ground. The sprinkler system company said a replacement pipe was not available and that they might have to “fabricate” the pipe, but that would be the facility’s decision. On February 4, 2023, at 1:15 pm, a general observation was conducted with the maintenance supervisor, at the south-east corner of the rear premises. It was observed that there was a hole (4 feet deep, 6 feet wide and 6 feet long) next to the fence, with 5-inch pipe that was detached and there was no liquid waste on the ground or in the hole. On February 4, 2023, at 2:00 pm, an interview was conducted with the administrator regarding the facility’s sprinkler system. During this interview, the administrator stated that his contractor would have the paperwork for this repair. February 4, 2023, at 2:30 pm, an interview was conducted with the contractor regarding the facility’s sprinkler system. The contractor stated that he was in communication with HCAI supervisor and he will get the emergency authorization, immediately. (HCAI is 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 buildings to comply with State codes.). February 9, 2023, at 3:15 pm., a revisit was conducted at the facility. The administrator was informed of the revisit. February 9, 2023, at 3:30 pm, an interview was conducted with the administrator. The facility’s final decision will be to replace all the pipes, from the riser to the facility. The administrator called the contractor and was asked if he had an emergency authorization to do the repair work. The contractor stated that he was in the process of submitting paperwork to HCAI’s emergency authorization. He should have the emergency authorization by February 10, 2023. February 9, 2023, at 4:30 pm, an interview was conducted with the administrator regarding the attempt to repair the broken water sprinkler pipe, without the proper paperwork from HCAI. The administrator stated he was unaware that the facility needed HCAI’s approval whenever there is any repair work to the facility. This deficient practice of could have negative effects to the health, safety, and welfare of the occupants in the facility. The facility failed to obtain the necessary permits/construction sign-off final approval from the HCAI for the unpermitted replacement/repair of a water supply pipe for the facility’s fire sprinkler system. The above violations had a direct or immediate relationship to the health, safety, or security of all patients.