Health inspection·January 2, 2025

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. The following reflects the findings of California Department of Public Health during the investigation of Complaint # CA00935530 survey. Event ID: 953711 Representing the Department, HFEII # 43229 and HFEI # 48350 State Citation (B) was written On 12/17/2024 at 1:45 pm, the California Department of Public Health (CDPH, the Department) made an unannounced visit at the facility to investigate a complaint regarding the physical environment. The facility did not have the written authorization, building permits or construction approval for the alterations from the Department of Healthcare Access and Information [HCAI, previously known as the Office of Statewide Health Planning and Development (OSHPD)] for the alterations to the facility’s fire alarm panel. The facility failed to comply with California Code Regulations, Title 22, Article 6, Sections 72601(a), including but not limited to, obtaining required written authorization, building permits, or attain construction approval for the alterations to the facility’s fire alarm panel from the Department of Healthcare Access and Information (HCAI, the State Agency). As a result, the facility did not have the written authorization, building permits or attain construction approval for the alterations to the facility’s fire alarm panel from the Department of Healthcare Access and Information (HCAI, the State Agency). This failure had a direct or immediate relationship to the health, safety, or security of the patients or residents. During a review of HCAI’s Construction Advisory Report – Investigation, the Unauthorized Construction Investigation, dated 1/16/2024, the documentation indicated “Walked the Nurse Station, appears a new Fire Alarm control panel was installed in 2023. A request was made onsite today for the permitting information. A search of the recently permitted OSHPD projects shows that the project was not permitted. It appears that the work was performed and completed without Office involvement. This is in violation of the California Administrative Code, Section 7-113, 7-128, & 7-135. The facility is requested to provide the permits for the work that has been completed or submit plans and related documents for approval and required permits as required by the California Building Code, Section 105.1.” During an interview on 12/17/2024 at 2:00 PM with the Administrator (ADM), the ADM stated that the facility’s fire panel had been repaired on 12/9/2024. During an interview on 12/17/2024 at 2:01 PM with the Maintenance Supervisor (MS), the MS stated that two years ago the original fire panel had stopped working and the vendor could not repair it. During an interview on 12/17/2024 at 2:03 PM with the MS, the MS stated that two years ago the entire fire panel was replaced and on 12/9/2024, the inside motherboard was replaced. During an interview on 12/17/2024 at 2:04 PM with the ADM, the ADM stated that he has been in communication with someone at HCAI’s. During an interview on 12/17/2024 at 2:04 PM with the ADM and MS, the ADM stated that the facility’s administrator and MS are responsible for obtaining permits or approvals. During an interview on 12/17/2024 at 2:11 PM with the MS, the MS stated that two years ago the original fire panel had to be replaced because the vendor could not find the replacement parts for that fire panel. During an interview on 12/17/2024 at 2:12 PM with the ADM, the ADM stated that he notified California Department of Public Health (CDPH) when the fire panel was replaced on 12/9/2024. During an interview on 12/17/2024 at 2:14 PM with the MS, the MS stated he does not know if management team obtained permits or approvals when the fire panel was replaced two years ago. During an interview on 12/17/2024 at 2:15 PM with the ADM, the ADM stated that the facility did not get prior approval with HCAI when the fire panel was being repaired. During an interview on 12/17/2024 at 2:15 PM with the ADM, the ADM explained the importance of obtaining HCAI’s authorization, approval, and permit for alterations or construction in the facility and stated, so that “It is done properly and done safe. That is the regulation”. During an interview on 12/17/2024 at 2:18 PM with the MS and ADM, the MS stated that the fire alarm panel was first replaced two years ago, on 1/14/2023. The MS stated that the fire alarm panel was “too old”, and the facility was having problems with the fire alarm panel. The fire alarm services vendor could not find parts for the fire alarm panel and the vendor decided to replace the whole fire alarm panel. The MS also stated that the fire alarm panel was reprogrammed when it was first replaced “because it was a different program before”. The ADM stated that the facility did not obtain approval from HCAI for the replacement of fire alarm panel. The ADM explained that it was the facility administrator’s responsibility to obtain HCAI’s approval for the replacement of the fire alarm panel. The MS stated that he was not aware that the facility was required to obtain HCAI’s approval prior to the replacement of the fire alarm panel. During an interview on 12/17/2024 at 2:21 PM with the MS, the MS stated that the fire alarm panel began beeping and was called at the nursing station where the fire alarm panel was located. He stated that the fire alarm panel was working on batteries and had power but the panel itself was not working. That is when he found out that the system was down. The facility initiated their fire watch procedures (the assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers) since he believed the smoke detectors (a device that detects visible or invisible particles of combustion) and manual pull station (a manually operated device used to initiate a fire alarm signal) would not alarm and fire signals would not be sent to the central monitoring station (a remotely located supervising station that receives signals from alarm systems and at which personnel are in attendance at all times to respond to these signals). The MS stated the fire alarm panel was replaced on 12/9/2024. During an interview on 12/17/2024 at 2:33 PM with the MS, the MS explained the purpose of a fire alarm panel and stated, it is to protect the facility when there is a fire. The MS also stated that he expected the fire alarm services vendor to come to the facility every three months to service the fire alarm system but, “they never come”. The MS was unable to provide documentation to show that the fire alarm system was regularly serviced (including inspection, testing, and maintenance). During a review of the facility’s correspondence with HCAI on 12/17/2024, the report indicated the following: i. On 12/9/2024, the ADM emailed HCAI compliance officer stating that the facility had repaired the fire panel on this day and to reach out to the facility on getting the work permitted. ii. On 12/12/2024, the ADM sent an email to HCAI compliance officer stating that the fire panel was repaired and wants to see how to get the work done to the fire panel permitted. iii. On 12/13/2024, Compliance Office at HCAI replied to an email to ADM stating instructions on how to apply for HCAI projects. iv. On 12/17/2024, ADM emailed HCAI compliance officer asking if he was available to go over the steps over the phone. v. On 12/17/2024, HCAI Officer replied to ADM stating that the project needs to be done with a design professional and approved plans for the location, mounting, and connections. And that retesting of the system will also be required with the Fire and Life Safety Officer. During an interview on 12/17/2024 at 2:39 PM with the ADM, the ADM explained the purpose of a fire alarm panel and stated, in case there is a fire, the fire alarm panel will notify the facility, notify 911, and notify the Emergency Medical Services. During a concurrent interview and record review on 12/17/2024 at 3:06 PM with the MS, the facility’s “Fire Watch Log,” dated from 10/18/2024 to 12/13/2024, was reviewed. The log indicated that the fire watch procedures were initiated on 10/18/2024. The MS stated that the facility began their fire watch on 10/18/2024 when the fire alarm panel “went down”, “stopped working”, and had “no power”. During an interview on 12/17/2024 at 3:09 PM with the MS, the MS stated that the fire panel was replaced on 1/14/2023 because the fire panel could not be repaired. During a concurrent interview and record review of the facility’s “Event History” Report, dated 12/13/2024 on 12/17/2024 at 3:12 PM with the MS, the MS stated that he tested the fire alarm system on 12/13/2024, which included one smoke detector and two manual pull stations. The event history report did not indicate that the alarm signals were received by the central monitoring station (a company that provides services to monitor the fire alarm system and alert the appropriate authorities in the event an alarm signal is received) on 12/13/2024. The MS stated that previous event history reports sent by the fire protection services vendor would indicate signals sent by each tested device and the current report dated 12/13/2024 did not show the signals or events. During a review of the facility’s previous Fire Alarm Vendor Invoice, dated 1/18/2023, the report indicated that technicians conducted an onsite visit to the facility to replace the non-operating fire alarm control panel. During a review of the facility’s Fire Alarm Panel Vendor Repair Service Agreement, dated 11/5/2024, the document indicated that technicians conducted an onsite visit to the facility on that date for a quote to conduct repairs. During a review of the facility’s Fire Alarm Vendor Invoice, dated 12/9/2024, the report indicated that technicians conducted onsite visit to the facility to repair the fire alarm panel. During an interview on 12/17/2024 at 3:35 PM with the MS, the MS explained that the first time the fire alarm panel was replaced was because the vendor could not find parts to repair the fire alarm panel and the second time the fire alarm panel was replaced was because there was no power in the fire alarm panel. The MS stated, (it) “maybe (the) same problem” and “they replaced it again”. During a concurrent observation and interview on 12/17/2024 at 3:42 PM with the MS and ADM, the MS tested the smoke detector located outside Room 33 by spraying the smoke detector with a canned aerosolized smoke. The smoke detector did not set off the alarm after the MS sprayed it three times. The MS stated, “normally it goes right away” when tested. During an observation on 12/17/2024 at 3:44 PM with the MS and ADM, the MS tested the smoke detector located outside the Nurse Station by spraying the smoke detector with a canned aerosolized smoke. The smoke detector did not set off the alarm after the MS sprayed it. During an observation on 12/17/2024 at 3:47 PM with the MS and ADM, the MS tested the smoke detector located outside the Nurse Station the second time by spraying the smoke detector with a canned aerosolized smoke. The smoke detector did not set off the alarm after the MS sprayed it. During an observation on 12/17/2024 at 3:50 PM with the MS and ADM, the MS tested the smoke detector located outside the Nurse Station the third time by spraying the smoke detector with a canned aerosolized smoke. The smoke detector did not set off the alarm after the MS sprayed it. During an interview on 12/17/2024 at 4 PM with the MS, the MS stated that he doesn’t know what happened to the smoke detectors and why the two smoke detectors were not working. During an interview on 12/17/2024 at 4:13 PM with the ADM, the ADM stated that he could not find a current contract with the current vendor that services the fire alarm as the original company had been transferred over to the current vendor. During an interview on 12/17/2024 at 4:13 PM with the ADM, the ADM stated he is not sure when the last Fire Alarm was serviced, except when the vendor came to repair the fire panel on 12/9/2024. During an interview on 12/17/2024 at 4:14 PM with the ADM, the ADM stated he will get a current contract with the vendor and be sure everything is done in a timely manner and that the MS will be in charge for scheduled testing. During an interview on 12/17/2024 at 4:23 PM with the MS, the MS stated that he does not have any documentation available showing when the last time was the fire panel had been inspected and serviced. MS stated he only had the activity reports available. During a review of the facility’s “Event History” report, dated 12/17/2024, the report indicated that all four of the fire alarms testing signals did not get sent to the central monitoring station. During an interview on 12/17/2024 at 4:39 PM with the MS, the MS stated that he didn’t know why the signals were not sent to the central monitoring station and stated he did not see any events shown on the activity report which are supposed to be shown on the report. During an interview on 12/17/2024 at 4:44 PM with the vendor, the vendor stated that the MS placed the fire alarm system on test at 3:30 PM and that the alarm cleared test at 4:08 PM. The vendor acknowledged that no signals were shown in the event history report on any of the tested devices and that the signals should be showing, and he didn’t see any. During a review of the facility’s policy and procedure (P&P) titled, “Fire System Maintenance”, dated 4/2015, under “PROCEDURE” section, the P&P indicated that the facility will, “Check fire alarm panel for any “trouble” indicators on the panel readout. Assure that maintenance staff has been thoroughly In-serviced on fire alarm and sprinkler systems by the fire alarm vendor.” During a review of the facility’s policy and procedure (P&P) titled, “Maintenance Services”, dated 10/1/2024, under “Procedure” section, the P&P indicated that “Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, D. Maintaining the fire alarm system, sprinkler system, and emergency generator system in good working order;” and that “The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings grounds, and equipment are maintained in a safe and operable manner.” During a review of the facility’s policy and procedure (P&P) titled, “Fire Watch”, dated 10/1/2023, under “Procedure” section, the P&P indicated that, “The designated staff member will be responsible for: A. Notifying the local fire department, local health facilities inspection division office and occupants of the Facility of the inoperable systems(s), the estimated time of repair, and an additional notification when the system(s) are repaired.” In violation of the above cited standards, facility failed to comply with California Code Regulations, Title 22, Article 6, Sections 72601(a), including but not limited to, obtaining required written authorization, building permits, or attain construction approval for the alterations to the facility’s fire alarm panel from the Department of Healthcare Access and Information (HCAI, the State Agency). As a result, the facility did not have the written authorization, building permits or attain