Other·April 25, 2024

§ 72603. Space Conversion. Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the approval of the Department. HSC 1271.1 (a) A health facility may place up to 50 percent of its licensed bed capacity in voluntary suspension for a period not exceeding three years, upon submitting written notification to the state department and to the Office of Statewide Health Planning and Development. However, this section does not authorize a health facility to deactivate all beds utilized for the provision of a basic service or to deactivate all beds utilized for a special service or other supplemental service for which the health facility holds a special permit or licensure approval. Prior to the expiration of the voluntary suspension, the health facility may request an extension, that may be granted by the director if the director finds, after consultation with the Director of the Office of Statewide Health Planning and Development, that there is no identified need for additional beds (of the category suspended) in the service area of the health facility. If during a period of voluntary suspension under this section the statewide Health Facilities and Services Plan identifies a need for additional beds (of the category suspended) in the health facility's service area, the Director of the Office of Statewide Health Planning and Development may require the health facility to terminate the voluntary suspension and exercise one of the following options, at the discretion of the health facility: (1) place some or all of the suspended beds in operation, in accordance with the identified need, within one year following his or her order, or (2) alternatively have the beds deemed permanently converted to other than patient use within the meaning of Section 1268. (b) A health facility may remove all or any portion of its voluntarily suspended bed capacity from voluntary suspension by request to the state department, which request shall be granted unless the areas housing the suspended beds fail to meet currently applicable operational requirements or fail to meet construction requirements for the health facility in effect at the time the request for suspension of the beds was received by the state department. (c) While health facility beds are in suspension pursuant to subdivision (a), the beds shall not be deemed to be permanently converted to other than patient use, for purposes of Section 1268. The requirements of this section shall not apply to any temporary deactivation of beds necessitated by the work of construction or other activities required with respect to a project for which a certificate of need or certificate of exemption has been granted pursuant to Chapter 1 (commencing with Section 127125) of Part 2 of Division 107. Nothing in this section shall in any way limit or affect the authority of a health facility to use a portion of its beds in one bed classification in another bed classification as permitted by subdivision (a) of Section 127170, including the use of general acute care beds as skilled nursing beds; provided, however, that when beds in a particular classification are suspended pursuant to this section, the remainder of the health facility's beds in the same classification may not be used so as to result in elimination of all beds utilized for provision of a basic service or utilized for provision of a special service or other supplemental service for which the health facility holds a special permit or licensure approval. On 3/12/24 at 8:30 a.m., an unannounced visit was made to the facility by California Department of Public Health during the facility’s Annual Health Recertification Survey. The facility failed to submit a written notification to the California Department of Public Health (CDPH) before placing twenty-three (23) licensed beds (Rooms 40 to 45 in South Wing) on voluntary suspension for an indefinite number of years. During an interview on 3/12/24 at 10:12 a.m. with the Administrator (ADM), the ADM stated the facility had a separate building within the facility’s premises, which was called South Wing (SW), that used to have 23 licensed residents’ beds. The ADM stated the building was not in use for patients’ care since she started working in the facility about two and a half (2.5) years ago and she did not know why. The ADM stated, the previous ADM of the facility informed her that the SW building had been used as a facility storage. The ADM added, there were no resident’s bed in the building, and the facility used the SW building for storage purposes only. During an interview on 3/12/24 at 11:22 a.m. with the ADM, the ADM stated, the facility was licensed for 96 patient beds and only utilized 73 beds for patient use. The ADM stated the SW building used to have 23 beds. The ADM stated, she did not verify with the facility’s corporate staff what happen to the 23 licensed patient beds in the SW building and why the SW building was not in use. The ADM stated she did not notify the 23 licensed suspended beds to CDPH. On 3/12/24 at 3:32 p.m., during a concurrent observation of the rooms in the SW building and interview with the ADM and the Maintenance Supervisor (MS) by Room 40, the room was observed with multiple items including binders, cartons, soda cans, and a 16 cube storage organizer with variety of food items, one open large plastic trash bag with empty soda cans, and one tied large plastic trash bag with empty soda cans were observed hanging on the side of a tray cart. The ADM stated the cart was used for activity. During a concurrent observation and interview on 3/12/24 at 3:35 p.m. with the ADM and the MS in the hallway of the SW building, multiple items was observed along the hallway including six drawers with full of storage items, four brown cartons, plastic bags, two chemical bottles, a white board, wheelchairs, boxes of documents, etc. The ADM stated, “nothing is working in this building, including the Exit Call light by the facility hallway. During a concurrent observation and interview on 3/12/24 at 3:38 p.m. with the ADM and the MS in front of Room 41, multiple items were observed including boxes of can liner, sanitizers, paper rolls, cleaning supplies, etc. The ADM stated, Room 41 had been used for housekeeping storage. During a concurrent observation and interview on 3/12/24 at 3:40 p.m. with the ADM and the MS in Room 42, four drawer and more than 20 boxes of random paper documents were observed. The ADM stated, Room 42 had been used for Director of Staff Development’s storage. During a concurrent observation and interview on 3/12/24 at 3:41 p.m. with the ADM and the MS in front of the SW building Shower room, more than 20 boxes with supplies including sanitizing cloths, plastic bottles, etc. were observed. In the shower area, boxes of surgical masks and supplies were observed. The ADM stated, the room had been used to store the facility’s central supplies. During a concurrent observation and interview on 3/12/24 at 3:42 p.m. with the ADM and the MS in front of Room 43, multiple items were observed on the floor and two metal racks including more than thirty plastic bags of linens, six cartons of supplies, one pair of black boots, two black storage container, one red cooler, etc. The ADM stated, Room 43 had been used for emergency linen storage. During an interview on 3/12/24 at 3:44 p.m. with the ADM in the hallway of SW, the ADM stated, she was informed by the facility’s corporate staff that the building was not in use for patient’ care because of a problem with the SW building’s sprinkler system. The ADM stated, she did not know exactly what was wrong with the sprinkler system. The ADM stated, she was just informed by the corporate staff that “the sprinkler needs to be updated.” During a concurrent observation and interview on 3/12/24 at 3:46 p.m. with the ADM and the MS in an open area connecting the hallway and Room 45, multiple items were observed including at least 10 empty five-gallon plastic bottles, approximately more than 20 five-gallon plastic bottles of water, at least 15 white boxes and several brown boxes with hand written “Discharge,” “Financial folder,” of residents’ document, brown boxes of supplies, lockers, etc. The ADM stated, the area had been used to store emergency water, supplies, and old patients’ documents. During a concurrent observation and interview on 3/12/24 at 3:48 p.m. with the ADM and the MS in Room 44, multiple items were observed including an office desk with variety of items including food covering the whole desk, an office chair, maintenance supplies covering more than half of the room. The ADM stated, Room 44 had been used like the “maintenance workshop.” The MS stated, he used this room for maintenance supplies. During a concurrent observation and interview on 3/12/24 at 3:52 p.m. with the MS in Room 44, a plastic trash bag with empty soda cans and bottles was observed hanging next to the office desk, the MS stated, there should be about 20 cans and bottles in the bag. The MS stated he collected the cans. The MS confirmed that it could be up to 100 empty cans in the Activity Room (Room 40), and it be thrown out. During a concurrent observation and interview on 3/12/24 at 3:55 p.m. with the ADM and the MS in Room 45, multiple items were observed including boxes of patients’ documents, old medical devices, resident’s bed and mattress, two linen carts, etc. The ADM stated the room was used for general storage, and stated, they kept old medical documents in most of the rooms and maintenance workshop instead of putting them in the office. During an interview on 3/13/24 at 11:30 a.m. with the ADM, the ADM stated, the SW building was originally built without a sprinkler system. The ADM stated she did not know when the SW Building was built several years ago. The facility failed to submit a written notification to the California Department of Public Health (CDPH) before placing twenty-three (23) licensed beds (Rooms 40 to 45 in South Wing) on voluntary suspension for an indefinite number of years. The above violation had a direct or immediate relationship to the health, safety, or security of patients, visitors and facility staff.