Health inspection·September 17, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Entity Reported Incident (ERI) #: 2605441 ERI Survey ID: 1D5B1F-L1 Representing the Department: HFE I #48350, HFE I #47348 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 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. On 9/2/2025 at 2 PM, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate an entity reported incident regarding the physical environment. The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from the 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) for the replacement of the busbar (metallic bar used to conduct and distribute electricity between multiple devices) within the facility’s main electrical panel (central distribution point for electricity in a building). As a result, 371 residents were placed at risk of accidents from the unauthorized installation of the replacement busbar. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an observation on 9/2/2025 at 2:01 PM with the Administrator (ADM), the lights inside the facility were turned off and only the emergency lights were turned on. During an interview on 9/2/2025 at 2:08 PM with the ADM, the ADM stated the facility’s power was scheduled to be turned off between 1:30 PM to 3:30 PM for repairs to the electrical panel. During a concurrent observation and interview on 9/2/2025 at 2:13 PM with the ADM and Electrician (EEC) at the electrical panel, work was being conducted. The EEC stated that one circuit breaker (electrical switch designed to protect an electrical circuit from damage) was being replaced in the electrical panel for a partial area of the exhaust in the kitchen. During a concurrent observation and interview on 9/2/2025 at 2:19 PM with the Director of Environmental Care (DEC) in the corridor, the power in the facility came back on. The DEC stated the work must be finished, which is why the power has been turned back on in the facility. During an interview on 9/2/2025 at 2:22 PM with the EEC, the EEC stated the electrical panel work was finished, and it took around 36 minutes to finish. During an interview on 9/2/2025 at 3:37 PM with the Assistant Administrator (AADM), the AADM stated that HCAI was not informed of the main electrical panel work and the temporary power shut off in the facility since it was just a repair, so no permit was required. During an interview on 9/2/2025 at 3:50 PM with the DEC, the DEC stated the vendor did not leave a receipt or any documentation. The DEC stated she would call them to inquire about getting a receipt. During an interview on 9/2/2025 at 3:53 PM with the AADM, the AADM stated that she would call the ADM to confirm if HCAI had been notified of the power shut off in the facility. During a concurrent interview and record review on 9/2/2025 at 4:25 PM with the DEC, e-mail correspondence from the facility’s vendor, dated 9/2/2025, was reviewed. The e-mail correspondence indicated, “On an emergency basis…responded earlier today to remove and replace Circuit Breaker CB #5 along with the burned-out middle-phase buss bar, on the 208/120 3-Ph Main Electrical Panel.” The DEC stated the vendor sent this e-mail describing the work that was conducted on the electrical panel on 9/2/2025. During an interview on 9/2/2025 at 4:26 PM with the DEC, the DEC stated that no one in the facility had called or inquired to HCAI if a permit would be required when the power to the facility would be shut off for repairs. The DEC stated the facility would contact HCAI right away to apply for the emergency permit as soon as possible. During a telephone interview on 9/3/2025 at 8:18 AM with the HCAI Fire and Life Safety Officer (FLSO), the FLSO stated the facility would have to notify HCAI and provide a second emergency generator if the facility had a planned power shut off for repairs to the electrical panel. During an interview on 9/5/2025 at 11:35 AM with the ADM, the ADM stated it is important to obtain HCAI approval prior to completing the work on the electric panels, to ensure compliance with regulatory guidelines. During an interview on 9/5/2025 at 11:40 AM with the ADM, the ADM stated their environmental consultant, and their outside contractor are responsible for notifying HCAI and obtaining approval/permits prior to commencing the work. During a review of the facility record titled, “Invoice,” dated 9/2/2025, the record indicated, “EMERGENCY REPAIR on 9/02/25…REPLACE BREAKERS FOR CIRCUITS 5 AND 6…REPLACE MIDDLE PHASE BUS BAR.” During a review of e-mail correspondence from the HCAI Compliance Officer (CO), dated 9/4/2025, the CO provided information to the facility and indicated work on the circuit breaker is considered excluded. The e-mail did not indicate whether replacement of a busbar is considered excluded work. During a review of e-mail correspondence from the HCAI Regional Compliance Officer (RCO) dated 9/4/2025, the e-mail indicated, “The attachment…indicated that a bus bar was replaced. This does not fall under excluded work.” The e-mail also indicated, “Since a busbar was replaced a project is required to mitigate the unpermitted work.” A review of the facility’s policy and procedure (P&P) titled, “Maintenance Services,” dated 6/1/2017, the P&P indicated, “Functions of the Maintenance Department may include, but are not limited to…Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.” The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from HCAI for the replacement of the busbar within the facility’s main electrical panel. As a result, 371 residents were placed at risk of accidents from the unauthorized installation of the replacement busbar. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.