Other·June 17, 2024

Title 22 Article 6 Physical Plant California Code Regulations, Section 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. California Code Regulations, Section 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 6/3/2024 at 8:40 AM, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to conduct the Life Safety Code survey and investigate a complaint regarding the physical environment. The facility failed to obtain required written authorization, building permits, or attain construction approval for: A-1. Alterations to the facility’s emergency and standby power systems (emergency generator) and associated equipment; and A-2. Installation of temporary/rental generator from the Department of Healthcare Access and Information (HCAI, the State Agency that reviews and approves plans for construction, repairs, renovations, and alterations made to healthcare facilities to comply with State Building Codes previously known as the Office of Statewide Health Planning and Development - OSHPD). B. The facility also failed to notify the Department within five days of the commencement of any alterations to the skilled nursing facility. As a result, the facility did not have the written authorization, building permits or attain construction approval for the alterations to the facility’s emergency, standby power systems and the installation of the temporary/rental generator from HCAI. A - 1. During an interview on 6/3/2024 at 1:37 PM with the Maintenance Supervisor (MS), the MS stated that the facility’s permanent generator went out of service in 2023 and a work order was submitted to repair the permanent generator. During an interview on 6/4/2024 at 9:25 AM with the MS regarding repairs done to the permanent generator, the MS stated that the fuel pump and electrical panel was replaced. During an interview on 6/4/2024 at 9:31 AM with the MS, the MS stated that the facility’s emergency generator powers the red outlets, call lights, emergency lights, and the fire alarm system. During an interview on 6/4/2024 at 9:46 AM with the Director of Nursing (DON), the DON stated that services the facility provide to its residents included rehabilitation services, long term stay, short term stay, and subacute care (a level of care provided on an inpatient basis for those individuals needing services that are more intensive than those typically received in skilled nursing facilities but less intensive than hospital acute care). During an interview on 6/4/2024 at 9:49 AM with the DON regarding the types of medical equipment that would be powered by the emergency generator in case of a power failure, the DON stated, ventilators (a life-support machine that helps a person breathe if they can no longer breathe on their own), oxygen machine (also known as oxygen concentrator, a medical device that gives a person extra oxygen), low air loss mattresses (a mattress designed to prevent and treat pressure wounds), suction machines (also known as an aspirator, is a type of medical device that is primarily used for removing obstructions like mucus, saliva, blood, or secretions from a person's airway), feeding tube machines (a medical device that is used to deliver nutrients directly into the gastrointestinal tract of a patient who is unable to take food or liquids orally), and refrigerators for medication. During an interview on 6/4/2024 at 9:53 AM with the Administrator (ADM) regarding the facility’s permanent generator’s failure, the ADM stated that the generator displayed low battery codes and that the generator needed parts to be replaced. During an interview on 6/4/2024 at 9:56 AM with the ADM regarding HCAI’s approval and/or building permits for alterations made to the permanent generator and associated equipment, the ADM stated that the facility’s management team is responsible for obtaining permits or approvals. During an interview on 6/4/2024 at 9:57 AM with the ADM regarding how long the permanent generator has not been functioning, the ADM stated that on 7/20/2023, a technician was working on the generator to troubleshoot the generator failure. The technician determined that they could not get the generator to work. The ADM stated that, they called the facility’s management company to obtain a rental generator that same day. The ADM also stated that the facility is awaiting clearance testing on their existing, repaired permanent generator. During a review of the facility’s “Maintenance Crew” Work Order Form, dated 6/20/2023, authored by the previous maintenance supervisor, the form indicated, “low battery in emergency generator annunciator panel” and that battery replacement was required. During a review of the facility’s Generator Vendor Invoice, dated 2/14/2024, the report indicated that technicians conducted onsite visits to the facility on the following dates: i. On 6/22/2023, a technician indicated the following on the report: generator “unit had an alarm for low battery voltage and alarm cell. Checked battery and charger. Battery shows 13.1 volts. Under load, it drops to 11.2 vdc [volts of direct current] … Checked exercise battery ATS [automatic transfer switch] battery was replaced. Alarms are still showing.” Consulted to be a “controller issue. Tried to start unit and will not start. Checked fuel and filter … Tried to bleed the fuel system. No fuel is coming out of the injector pump. Recommend fuel injectors and pump to be rebuilt.” ii. On 6/27/2023, a technician indicated the following on the report: “Checked check valve and made sure we had fuel all the way to the injection pump. No fuel after the injection pump to the injectors. Changed out the injection pump and pulled injectors. Injectors are the correct part number although they are incorrect due to missing a crush fitting on the top of the injectors … Installed the old injectors with the new injection pump and tried to get the engine running. Could not get engine running injectors were very clogged when removing.” iii. On 6/29/2023, a technician indicated the following on the report: “Install new injectors and tried to run generator. Engine did not start, continue troubleshooting. After troubleshooting I found that the relay for the fuel injection pump solenoid is not engaging. I was able to get the engine to run when jumping power to solenoid although the controller is not sending signal to the relay. Check continuity from relay back to the controller and wiring is intact … we recommend replacing the controller.” iv. On 8/22/2023, a technician indicated the following on the report: Inspected unit. The unit had a different controller than the retrofit controller provided to the technician. Referred to other possible retrofit controllers available. During a review facility’s Generator Vendor Invoice, dated 4/30/2024, the report indicated that a technician conducted onsite visits to the facility on the following dates: i. On 3/14/2024, a technician indicated the following on the report: “Found unit off with battery disconnected. Began removing harness from engine side. Removed covers to breaker panel and controller. Opened shore power breakers that energize block heater, battery charger. Removed old harness and controller from unit.” ii. On 3/15/2024, a technician indicated the following on the report: “Begin removing old sensors (oil pressure, coolant level and temp sensors). Installed new sensor provided with kit. Installed new controller panel and mounted on tower. Installed new voltage sensing wires as well as CT wires on unit. Began wiring in new engine harness.” iii. On 3/18/2024, a technician indicated the following on the report: “Installed new wiring and engine sensors. Wired in voltage wires for injection pump governor and solenoid. Wired in DC alternator and starter contactor. Wired in start and ignition signals. Wired in coolant level sensor and ran DC power and DC ground where needed. Cleaned up and secured wiring, system did not come with a Mag Pick up [magnetic pickup] needed to locate one that will fit … bell housing.” iv. On 3/20/2024, a technician indicated the following on the report: Located and installed new magnetic pickup and wired into harness. “Installed GFCI [ground-fault circuit interrupter] outlets in unit to run block heater. Wired in battery charger and repaired battery terminal. At nurse’s station removed old annunciator from wall and installed new annunciator box. Wired in RS485 communication and DC power supply.” v. On 3/21/2024, a technician indicated the following on the report: “Made final connections to unit and powered up unit. Unit started up and ran. Found unit over voltage, installed voltage adjustment pot and corrected voltage output. Ran unit and found major exhaust leak coming from bent turbo clamp. Found white exhaust coming from unit and unit was running rough. Allowed unit to run for 10 minutes to see if unit clears up. Unit did not clear up and was still running rough. Possibly the injection pump was not installed in time and will need to be reset. Removed injection pump to have tested will need to return … with timing tool and remove timing cover.” vi. On 4/11/2024, a technician indicated the following on the report: “Drained oil and coolant from unit. Removed fan and fan pulley from unit. Removed radiator from unit and loosened and removed crank pulley. Removed timing cover from unit and cleaned off all surfaces. Set timing on gears and installed injection pump. Reassembled timing cover and installed fan and radiator. Filled unit with coolant and oil. Primed system and powered unit up. Unit started and ran adjusted injection pump … Found oil leak present from timing cover and unit is not producing full voltage. Will need to return to reseal timing cover and trouble shoot voltage issue. Unit is currently left in off position and rental is still connected.” vii. On 4/26/2024, a technician indicated the following on the report: “Drained coolant from unit. Removed fan guard. Removed upper and lower radiator hoses. Removed fan and shroud. Removed radiator from unit. Removed front scoop cover to gain access to timing cover. Removed crank pully and timing cover. Cleaned all surfaces and applied gasket maker to timing cover. Resealed timing cover and replaced front crank seal. Reassembled radiator and fan and filled with coolant. Gave silicon time to set, once set ran unit. And checked AVR [automatic voltage regulator]. Found voltage pot connector loose and not making good connection to AVR. Resecured connection and tested unit. Found that unit to produces proper voltage. Connected load bank to unit and performed load bank. Load bank for 30 mins [minutes] and got up to 80%. No leaks present and unit operated as designed. Removed load bank and connected customer wires back on breaker … reconnect stand by generator back to transfer switch. Removed temp [temporary] gen [generator] pig tails and found E 1 (emergency leg 1) lug burnt and threads stripped. Attempted to clean and cut new threads but lug is badly damaged. Called in and had rental ATS deployed. Once rental ATS arrived on site set in electrical and Polaris connected Load, Utility and Emergency conductor to temporary ATS. Wired in 2 wire start. Energized ATS and set all timers. Set unit to auto with breaker closed and performed transfer test. Unit operates as designed. Returned power back to ATS and unit transferred back and cooled down. Will need to replace ATS contractor.” During a review of HCAI Report Center on 6/4/2024, the facility did not have any projects regarding alterations or repairs to the permanent generator and associated equipment. During an interview on 6/4/2024 at 11:59 AM with the ADM, the surveyor requested for HCAI’s written approval or authorization for the alterations made to the permanent generator and associated equipment, the ADM stated the facility did not have that documentation. A - 2. During an observation on 6/4/2024 at 9:16 AM in the parking lot on the East side of the building in front of the main electrical panel, there was a temporary/rental emergency generator connected to a trailer with wheels. There was no HCAI permit posted for the installation and use of the temporary generator. During an interview on 6/4/2024 at 9:56 AM with the ADM regarding HCAI approval and/or building permits for the installation of the temporary/rental generator, the ADM stated that the facility’s management team is responsible for obtaining the permits or approvals. During an interview on 6/4/2024 at 9:57 AM with the ADM, the ADM stated that they called the facility’s management company to obtain a rental generator the day the technician determined that they could not get the permanent generator to work. During a review of HCAI Report Center on 6/4/2024, the facility did not have any projects regarding installation of a rental/temporary generator. During a review facility’s Generator Vendor Invoice, dated 7/30/2023, the report indicated, “28-day standby/single shift rental rate period 6/22/23 – [7/19/23]”. The report included “equipment hookup – tech labor and travel”, “equipment delivery charge” and “rental generator”. During a review facility’s Generator Vendor Invoice, dated 9/15/2023, the report indicated, “28-day standby/single shift rental rate period 8/17/23 – 9/13/23”. During a review facility’s Generator Vendor Invoice, dated 10/12/2023, the report indicated, “28-day standby/single shift rental rate period 9/14/23 – 10/11/23”. During a review facility’s Generator Vendor Invoice, dated 11/10/2023, the report indicated, “28-day standby/single shift rental rate period 10/12/23 – 11/08/23”. During a review facility’s Generator Vendor Invoice, dated 12/29/2023, the report indicated, “28-day standby/single shift rental rate period 12/07/23 – 12/31/23”. During a review facility’s Generator Vendor Invoice, dated 1/30/2024, the report indicated, “28-day standby/single shift rental rate period 01/04/24 – 01/31/24”. During a review facility’s Generator Vendor Invoice, dated 2/26/2024, the report indicated, “28-day standby/single shift rental rate period 02/01/24 – 02/28/24”. During a review facility’s Generator Vendor Invoice, dated 3/25/2024, the report indicated, “28-day standby/single shift rental rate period 02/29/24 – 03/27/24”. During a review facility’s Generator Vendor Invoice, dated 4/22/2024, the report indicated, “28-day standby/single shift rental rate period 03/27/24 – 04/23/24”. During a review facility’s Generator Vendor Invoice, dated 5/20/2024, the report indicated, “28-day standby/single shift rental rate period 04/24/24 – 05/21/24”. B. During an interview on 6/4/2024 at 11:52 AM with the ADM regarding notification to the Department regarding alterations to the facility’s emergency generator and associated equipment (including installation of temporary/rental generator), the ADM stated, “Management said they would take care of it.” The ADM confirmed no notification to the Department was made. A review of the facility’s policy and procedure (P&P) titled, “Emergency Operations Program and Plan Manual”, dated 3/21/2024, under “Alternate Sources of Energy” section, the P&P indicated that, “Our facility has developed procedures to ensure that we maintain safe temperatures for residents, sanitary storage of perishable provision, emergency lighting, fire detection, extinguishing and alarms … We have mitigated the impact of a power outa