Other·August 29, 2022

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: 2019 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 facility failed to obtain the requisite building permits/construction sign-off final approval from the Department of Healthcare Access and Information [HCAI, previously known as the Office of Statewide Health Planning and Development (OSHPD)] for the installation/replacement of: 1. Unpermitted installation of an icemaker, two 150-gallon boilers, and one 40-gallon water heater with one-seismic strap in the basement. 2. Unpermitted Communication/internet system installed on the 2nd floor. 3. Unpermitted water heater: one 40-gallon water heater was added prior to 2014. 4. A new handwashing fixture was recently installed at the direction of Los Angeles County Department of Public Health in the kitchen area. The sink was installed without benefit of a HCAI Building Permit and final inspection. 5. An unpermitted swamp cooler (a machine that works as an air conditioning unit) was installed on the roof. 6. Unpermitted installation of a gasoline type emergency generator. As a result, all residents were placed at risk of accidents, including fire, from unauthorized equipment. On 7/15/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about the physical environment. On 7/15/2022 at 8:40 a.m., an interview was conducted with the facility’s Assistant Administrator. She stated that she was hired a month ago and all construction related questions would be deferred to the construction consultant because she is unaware of the status for any construction/remodeling projects. During a tour with the maintenance supervisor (MS) at 9:00 a.m., the following was observed: 1. The installation of an icemaker, two 150-gallon boilers, and one 40-gallon water heater in the basement. 2. Water heater: one 40-gallon water heater in the basement. 3. A new handwashing fixture was recently installed in the kitchen. According to an interview with the MS, the sink was installed at the direction of the Los Angeles County Department of Public Health. Also, the MS was not able to provide a HCAI Building Permit and final inspection sign off approval for the handwashing fixture installation. 4. On the roof, it was noted that a swamp cooler had been installed. According to an interview with the MS, the swamp cooler was installed within the past 3 years. The MS was not able to provide a HCAI Building Permit and final inspection sign off approval for the swamp cooler. 5. A gasoline type generator had been installed. The MS was not able to provide a HCAI Building Permit and final inspection sign off approval for the emergency generator. On 7/15/2022 at 11:30 a.m., during an observation of the basement and the above components and a concurrent interview with the MS, the MS stated that he does not address construction projects, however, he does handle maintenance of the equipment. Record review of HCAI site visits on 7/26/2019 and 8/2/2019 indicate that the items listed above were observed to be non-compliant as follows: 1. It was determined during the site visit that the Ice Maker was recently added. The ice maker is over five feet tall and appears to weigh more than 100 pounds, no anchorage of the unit was observed. It appears that a new ice maker has been placed in the room without the benefit of design or inspection. The ice maker is in violation of the California Code of Regulations, Title 24, California Administrative Code, Sections 7-113 & 7-128. In compliance with the California Administrative Code, Section 7-113 the Facility shall apply for a project, submit plans and commence the plan review. 2. Boilers: two larger sized water heaters were observed to have been installed. The room had inadequate combustion air and ventilation. Air balance to be addressed per CMC Table 4A. One water heater had a manufactured date of 2013, the other of 2016. The water heaters installed with dates manufactured/installed after 2014 are required to be permitted when installed. It appears that one of the two water heaters were installed after 2014 without benefit of a Building Permit and inspection. This is in violation of the California Administrative Code, Section 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. As of January 1, 2014, the California Code of Regulations, Title 24, Part 1, Section 7-128 was chaptered to address construction performed without approval from the Office. Section 7-128 specifies that construction or alteration of any health care facility performed without the benefit of approval and/or observation by the Office shall be subject to examination by the Office to assess relevant code compliance. 3. Communication/internet system installed on 2nd floor: Facility informed me that the system had been added two years ago. It appears from a search of recently permitted projects that the rack was mounted without the benefit of an OSHPD design and inspection. This is in violation of the California Administrative Code, Section 7-135 and 7-128. 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 4. Water heater: one 40-gallon water heater was added prior to 2014. One strap was observed. All water heaters noted in compliant are required to be addressed as it appears they were not installed with the benefit of design or inspection. 5. It was observed that a new handwashing fixture was recently installed at the direction of LA County Health in the kitchen area. It appears that the sink was installed without benefit of a Building Permit and inspection. This is in violation of the California Administrative Code, Section 7-135 and 7-128. 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. Chlorination, pressure testing and sink supports to be completed. 6. On the roof, it was noted that a swamp cooler had been installed within the past 3 years, support was not tied to the roof/structure adequately. It appears the swamp cooler was installed without the benefit of design or inspection. This is in violation of the California Administrative Code, Section 7-135 and 7-128.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 Record review of a HCAI construction advisory report dated 8/2/2019, the author of the report, HCAI inspector 1, indicated the following HCAI non-compliant construction/alteration items: 1. There is a new gasoline type generator. The tag affixed to the equipment revealed the first annual inspection occurred in 2014. No permit available at the time of the survey. 2. Gasoline type generator: It appears that a gasoline type generator has been connected in 2013/2014 without the benefit of design or inspection. The generator is in violation of the California Code of Regulations, Title 24, California Administrative Code, Sections 7-113 & 7-128. In compliance with the California Administrative Code, Section 7-113 the Facility shall apply for a project, submit plans and commence the plan review, approval and building permit process or provide the permit used for the construction. Record review of HCAI construction advisory report dated 06/15/2021, the author of the report, HCAI inspector 1, indicated the following HCAI non-compliant construction/alteration items: 1. The basement had an installation of an icemaker, two 150-gallon boilers, and one 40-gallon water heater with 1-seismic strap. 2. Communication/internet system installed on the 2nd floor. Record review of a final HCAI construction advisory report dated 7/15/2022, stated that HCAI inspector 1 conducted a survey with facility construction consultant and MS. It was determined that the HCAI non-compliant emergency generator only received general maintenance and was not replaced. No other work was done regarding the items noted in the earlier reports dated 6/15/2021 and 8/2/2019. On 7/23/2022 at 10:30 a.m., during an interview with the facility construction consultant (FCC1), he stated that the facility was still in the process of applying for construction permits to comply with the unapproved HCAI construction items noted in the reports dated 6/15/2021 and 8/2/2019. Record review of an existing facility building project (S220680-19-00) to replace the existing kitchen hood canopy & exhaust systems and replace the existing kitchen make air system indicates an application for a new permit, dated 05/02/2022. However, it did not address the unapproved construction items noted in the reports dated 6/15/2021 and 8/2/2019. As a result, all residents were placed at risk of accidents, including fire, from unauthorized equipment replacement/installation. The above violation had a direct relationship to the health, safety, and security of all residents.