Health inspection·February 19, 2026

San Marino Healthcare Center Survey ID: 1DFC69-L1 Exit Date: 1/8/2026 Tag: K918 – Installation Without Authorization from HCAI San Marino Healthcare Center The following reflects the findings of the California Department of Public Health (CDPH) during the annual recertification survey. Survey ID: 1DFC69-L1 Representing the Department: HFEI # 51746 State Citation B was written. 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 1, 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. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. On 1/7/2026 at 8 am, CDPH made an unannounced visit to conduct the annual recertification survey. The facility failed to obtain the required written emergency authorization, building permit, construction approval, and attain substantial compliance from the California 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) prior to the installation of a temporary emergency generator (device for generating electricity that is used in the event of a power outage) and associated electrical alterations, including connections to the facility’s automatic transfer switch (ATS, device that shifts a facility’s power from the main utility to an emergency generator when the primary power source fails). As a result, 56 residents were placed at risk of accidents from the unauthorized installation of the temporary emergency generator system. This violation had a direct or immediate relationship to the health, safety, and security of patients or residents. During review of the facility’s report titled, “HCAI Project Closure Summary Report S222395-19-00, dated 12/29/2022, the summary report indicated, “The items listed below are currently outstanding on this project and require resolution. These items must be cleared before construction can proceed in the area covered by the item. Failure to clear these items is considered failure to construct the project in accordance with the approved construction documents and is a violation of Title 24, California Administrative Code Section 7-143 and will prevent HCAI from providing Substantial Compliance, Certificate of Occupancy, and Construction Final.” During a review of the invoice titled, “Invoice No: 20234 I-20,” dated 1/8/2023, the invoice indicated, “Status: Resubmittal to HCAI without Final Zoning Approval. Pending Final City Zoning Approval.” During a review of the “Generator Service Report” for a repair service, dated 1/25/2023, the permanent Generator Service Report indicated, “1-13-23: Performed urgent check of the emergency power generator due to report of not starting. 1. Upon arrival confirmed the generator start solenoid (circuit solenoid switch) was ‘clicking’ but the engine was not cranking when tested from the control panel. 2. The battery voltage under cranking was good (over 13 VDC). Note the battery charger output was over 14 VDC which can cause pre-mature battery failure. See recommendations. 3. The starter was removed and confirmed it was not turning when the generator was tested from the control panel. 4. The oil level was checked and was over full. The oil was not mixed with water but because the engine would not turn it is possible water is sitting at the bottom of the pan. 01-15-2023: Continued repair: 1. Replaced the starter on engine. 2. Prior to cranking the generator the valve covers were removed to check for water and some water was found. More urgently two of the valve push rods were found broken and not in place. 3. Removed all the spark plugs and found some water on the spark plugs. Cranked the engine with the plugs out and water was expelled from all the cylinders. 4. Drained the oil pan and a lot of water was drained with the oil. 5. Checked the oil filter and it was contaminated with water. 1-25-2023: Completed repair: 1. Installed new push rods and replaced the valve covers. 2. Replaced the oil filter and refilled the engine with new oil. 3. Installed new spark plugs. 4. Tested the generator and operation was normal. Ran for about 20 minutes under load (242.8 VAC, E1=43.7A, E2=68.3A). 5. Disconnected the rental generator and reconnected the facility generator to the load wiring… Install protection for the generator exhaust so that rain water will not enter the engine.” During a review of “Invoice 28137,” dated 2/5/2025, Invoice 28137 indicated, “Generator Rental (four (4) Weeks), includes Trailer Mounted Generator and Power Cables.” During a review of “Invoice 28391,” dated 4/2/2025, Invoice 28391 indicated “Generator Rental (four (4) Weeks), includes Trailer Mounted Generator and Power Cables.” During a review of “Invoice 28546,” dated 4/30/2025, Invoice 28546 indicated “Generator Rental (four (4) Weeks), includes Trailer Mounted Generator and Power Cables.” During a review of the “Invoice 28613,” dated 5/28/2025, Invoice 28613 indicated “Generator Rental (four (4) Weeks), includes Trailer Mounted Generator and Power Cables.” During an interview on 1/7/2026 at 8:53 am with the Maintenance Housekeeping (MA), MA stated there have not been any work projects, renovations, changes or remodeling since the last survey. During an interview on 1/7/2026 at 11:18 am with MA, MA stated the facility’s permanent generator is not working so the company brought in a temporary generator on wheels about two months ago. The MA stated once the permanent generator is repaired, they will take the temporary generator out. The MA stated he does not know what the problem with the permanent generator is and his supervisor would know, but is on vacation. The MA also stated he does not know if the facility notified anyone that they were on a temporary generator. During a concurrent observation and interview on 1/7/2026 at 11:22 am with MA outside on the back grass area behind the laundry room, an Onon 80.0 Gen Set temporary generator was observed with the ATS set on automatic. MA stated the temporary generator operates on diesel fuel. MA also stated that he knows the temporary generator and ATS were set on automatic because they had a power outage about a week ago and the generator kicked on. During an interview on 1/7/2026 at 11:37 am with the Licensed Vocational Nurse (LVN), LVN stated the facility has no subacute residents in the facility. During an interview on 1/7/2026 at 11:41 am with MA, MA stated that he called the Facility Maintenance Supervisor (FMTS) and was told the [FMTS] thinks something is wrong with the motor but is not sure but that they are in the process of replacing the permanent generator. During an interview on 1/7/2026 at 11:53 am with Maintenance Regional Director (MTS), a verbal request was made for the permanent generator inspection, testing, service, and maintenance reports. MTS stated, “It has been an ongoing issue with the [permanent] generator for about a year or two.” During an interview on 1/7/2026 at 12:37 pm with MTS, MTS stated the earliest rental generator invoice they have is 4/30/2025 to 5/28/2025. During an interview on 1/7/2026 at 12:46 pm with MTS, MTS stated the following: a. Two different vendors said there was nothing they can do for the facility’s permanent generator back around 4/2025. b. MTS does not believe the generator has worked since 4/2025. c. MTS is not sure when HCAI was contacted. During an interview on 1/7/2026 at 12:46 pm with the ADM and MTS, a verbal request was made for the following documents: - Unusual Occurrence Policy and Procedure (P&P) - Generator P&P - General Maintenance P&P - Emergency Preparedness Plan for power outage - Emergency Preparedness Plan for generator failure - Invoices/vendor reports for the temporary generator, repairs made to the permanent generator, and indicating permanent generator is no longer repairable - Invoices/service records for permanent generator - Acceptance test documentation for temporary generator - Temporary generator switch documentation During an interview on 1/7/2026 at 1:02 pm with MTS, MTS stated the Administrator (ADM) does not have HCAI paperwork and is waiting for corporate to provide it. During an interview on 1/7/2026 at 1:11 pm with MTS, MTS stated ADM told him there is no HCAI documentation for the reporting of the rented temporary and have not notified HCAI. MTS further stated that they have recently reached out to HCAI to replace the generator. During an interview on 1/7/2026 at 2:23 pm with MTS, MTS stated corporate office is trying to resolve the issue with the rented temporary generator. MTS also stated corporate plans to open the project again to replace the generator. MTS also stated they do not have any other documentation available and is not aware if anyone contacted HCAI regarding the facility’s rented temporary generator. During an interview on 1/7/2026 at 2:38 pm with MTS, MTS stated he is only aware of two generator rentals. During an interview on 1/7/2026 at 2:41 pm with MTS, MTS stated, “The facility has never been without a generator of some sort.” During an interview on 1/7/2026 at 3:03 pm with ADM, ADM stated he does not know anything about a rental generator back in 2023. ADM also stated he began working in the facility in 7/2023. During an interview on 1/7/2026 at 3:17 pm with ADM and MTS, MTS and ADM stated that the vendor installed the temporary generator at the beginning of 4/2025 and are not aware of them doing an acceptance test on the temporary generator but assume they would have done all the necessary testing. The facility was not able to provide documentation of the temporary generator’s acceptance testing. During an interview on 1/7/2026 at 3:20 pm with ADM and MTS, ADM stated the facility has been on a temporary generator since 4/2025 to the present and will ask for the invoices as of 4/2025. During an interview on 1/7/2026 at 3:23 pm with ADM and MTS, ADM stated he knows that the rented temporary generator was switched for another rented temporary generator, and he does not know the reason why. ADM further stated that the facility was not charged for the switch, he did not request the change and would need to ask the FMTS if any documentation was provided. During an interview on 1/7/2026 at 3:23 pm with the ADM and MTS, a second verbal request was made for the following documents: - Unusual Occurrence P&P - Generator P&P - General Maintenance P&P - Emergency Preparedness Plan for power outage - Emergency Preparedness Plan for generator failure - Invoices/vendor reports for the temporary generator, repairs made to the permanent generator, and indicating permanent generator is no longer repairable - Invoices/service records for permanent generator - Acceptance test documentation for temporary generator - Temporary generator switch documentation During an interview on 1/7/2026 at 3:26 pm with ADM and MTS, ADM and MTS stated that the temporary generator is set on auto, and they know so because of the weekly testing that is being done. During an interview on 1/7/2026 at 3:27 pm with ADM and MTS, ADM stated he was not aware that HCAI needed to be contacted for the temporary generator. For other projects he does know that HCAI does need to be made aware for the safety of residents, ensure compliance and how the project is being done. ADM further stated that some examples of projects that he knows HCAI need to be contacted include adding a wing to a facility or converting certain things within the facility. During an interview on 1/7/2026 at 3:29 pm with ADM and MTS, ADM stated when it comes to projects, a project manager would be assigned, and that assigned person would be the person that would reach out to get the appropriate approvals. ADM also stated he has never had to deal with HCAI project approvals for any type of construction. During an interview on 1/7/2026 at 3:34 pm with ADM and MTS, ADM stated the vendor has been out trying to fix the generator many times and around 4/2025 the vendor said it was on “It’s last leg.” During an interview on 1/7/2026 at 3:35 pm with ADM and MTS, ADM stated the temporary generator provides the same services as the permanent generator. During an interview on 1/7/2026 at 3:36 pm with ADM and MTS, ADM stated he did not notify the department regarding the generator failing and that there was no time when the facility was without a generator. During an interview on 1/7/2026 at 3:39 pm with ADM and MTS, ADM stated the facility did not reach out to HCAI to request an emergency authorization for the installation of the temporary generator because he was not aware he had to do that. During an interview on 1/7/2026 at 3:45 pm with ADM and MTS, ADM stated he was aware that corporate wanted to replace the generator a long time ago but did not know why they did not go through with it. ADM also stated the facility’s permanent generator has been working since he began working at the facility 7/2023 to 4/2025. ADM also said he does not know how long the facility was on a temporary generator back in 2023. During an interview on 1/7/2026 at 4:26 pm with ADM and MTS, ADM stated if something were to go wrong or repairs are needed to the temporary generator, the vendor is responsible. A verbal request was made to the ADM for supporting documentation. The facility was not able to provide the requested documentation. During an interview on 1/7/2026 at 4:30 pm with ADM and MTS, MTS stated the vendor is responsible for conducting an acceptance test of the generator. ADM stated an acceptance test was important to ensure that in case of an emergency the generator will actually be working as needed. During an interview on 1/7/2026 at 4:32 pm with ADM and MTS, ADM and MTS stated that multiple vendors notified the facility that the generator was hard to repair because the parts were obsolete, too old, and got to the point where the facility was calling the vendor too often to come do repairs. A verbal request was made for supporting documentation to ADM. The facility was not able to provide the requested documentation. During an interview on 1/7/2026 at 4:37 pm with ADM and MTS, ADM stated the following: a. The plan for the facility is to eventually have a new, permanent generator, but is not able to provide a specific time frame but will find out. b. The overall goal is to have a new, permanent generator in the facility, since the rented temporary generator was put in place because they know that the facility’s permanent generator cannot be repaired anymore. During an interview on 1/7/2026 at 4:45 pm with the ADM and MTS, a third verbal request was made for the following documents: - Unusual Occurrence P&P - Generator P&P - General Maintenance P&P - Emergency Preparedness Plan for power outage - Emergency Preparedness Plan for generator failure - Invoices/vendor reports for the temporary generator, repairs made to the permanent generator, and indicating permanent generator is no longer repairable - Invoices/service records for permanent generator - Acceptance test documentation for temporary generator - Temporary generator switch documentation During an interview on 1/8/2026 at 8:20 am with the