Health inspection·August 3, 2023

72641. Emergency Lighting and Power System. (c) If the Department determines that an evaluation of the emergency electrical system of a facility or portion thereof, is necessary, the Department may require the licensee to submit a report by a registered electrical engineer which shall establish a basis for alteration of the system to provide reasonable compliance with Subarticle E702-B, Part 3, Title 24, California Administrative Code (Emergency Electrical Systems for Existing Nursing Homes). Essential engineering data, including load calculations, assumptions and tests, and where necessary, plans and specifications, acceptable to the Department, shall be submitted in substantiation of the report. When corrective action is determined to be necessary, the work shall be initiated and completed within an acceptable time limit. On, July 20, 2023, at 2:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Life Safety Code. The facility failed to ensure that the temporary emergency power generator was permitted, since obtaining the temporary emergency generator in October of 2022. This failure directly affected 39 patients residing in the facility. This deficient practice has the potential for the unregulated/unmonitored installation of the generator which may affect the facility’s ability to operate in an emergency power outage, affecting the facility’s ability to provide care to patients and rendering all electrical equipment, that are not battery powered, non-functional (such as refrigerators for food and medication, air mattresses, and oxygen therapy machines). A review of the facility’s Daily Census dated 7/20/23 indicated that the facility was housing 39 patients. On 7/20/23, at 2:11 p.m., during an interview with the Administrator (admin), Assistant Administrator (a. admin), and Director of Nursing (DON), the admin stated that plans were submitted to the Department of Healthcare Access and Information (HCAI - the authority having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling of healthcare buildings to comply with State codes) cannot recall when. The admin stated that the plans were returned to the facility from HCAI, on 7/18/23, for additions that needed to be made to the plans. These plans would be resubmitted to HCAI for review on 7/21/23. On 7/20/23, at 2:16 p.m., during observation, the temporary generator was observed on the south-east side of the building’s exterior. On 7/20/23, at 2:52 p.m., during an interview with the Facility Life and Safety Manager (L&S Manager), the L&S Manager stated that after the facility reported the emergency generator was stolen in October of 2022, the facility submitted an application for an emergency permit (a permit granted from HCAI that bypasses regular permit requirements for immediate action) from HCAI for the installation of a temporary emergency generator on 10/20/22 and this was closed by HCAI shortly after. The facility submitted a second request for a permit from HCAI on 11/1/22 and it is open until today. The L&S Manager provided a timeline for the history of the temporary generator permit, obtained from the HCAI online portal (an online service provided by HCAI for plan submittal and updates). During a concurrent interview and record review of the HCAI portal timeline, the timeline indicated that the project was opened on 11/1/22. There were no updates on the timeline until 4/24/23, which was the submission of a plan and the receipt from HCAI. The L&S Manager stated that after a meeting held with this department, HCAI, and the facility on 4/12/23, plans were made towards addressing the lack of permitting of the temporary generator. The L&S Manager stated that until now a plans for the permit has not been approved for the temporary generator. The contracted architect will submit the revised plans to HCAI for the use of the temporary generator by 7/21/23, at the earliest. Record review of an application for an emergency permit, dated 10/20/22, permit number X220044-19-00, indicated that an emergency permit was requested for the installation of a temporary generator. The HCAI portal indicated that this permit was closed administratively. Record review of an application for a permit, dated 11/1/22, permit number S221869-19-00, indicated that a permit was requested for the installation of the temporary generator. Review of the online portal indicated that the plans were marked as “returned” to the facility on 11/7/22. On 4/24/23, the plans were marked as “Plan Received”. The facility failed to ensure that the temporary emergency power generator was permitted, since obtaining the temporary emergency generator in October of 2022. The above violations had a direct or immediate relationship to the health, safety, or security of all patients.