Health inspection·March 6, 2026

Title 22 Article 6 Physical Plant 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 1/21/2026 at 9:20 AM, CDPH made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to obtain the required substantial compliance from the California 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) during the installation of a temporary emergency generator (device for generating electricity that is used in the event of a power outage) and associated electrical alterations, including connections to the facility's automatic transfer switch (ATS, device that shifts a facility's power from the main utility to an emergency generator when the primary power source fails). As a result, 41 residents were placed at risk of accidents from the unauthorized installation of the temporary emergency generator system. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During a review of the "HCAI Construction Advisory Report - Field Visit", the following were noted: a) The report dated 10/21/2022 indicated, "[Temporary] generator was located on the East side of the facility within [six inches] of the facility and within [two feet] of the adjacent non-OSHPD building. Location is required to be in compliance with... Noted the wiring for the unit are not in compliance with [California Electrical Code (CEC)] 590... For emergency repairs carried out without the Office plan review and permit in the aftermath of an emergency, an application for plan review must be submitted with construction documents, fees and a letter of transmittal stating the reasons for emergency repairs. b) The report dated 12/8/2022 indicated an HCAI field visit was conducted to "Test the temporary emergency generator. The generator failed to start and supply power to the facility within the maximum 10-second required by CEC 517.43. The facility is recommended to coordinate with the generator supplier to attain a generator that is capable of compliance. Documentation shall be submitted to the Office of the generator supplier's load-bank testing of the temporary generator as a means to verify compliance with [The National Fire Protection Association (NFPA)] 110 - 7.13.1.3." c) The report dated 10/18/2023 indicated, "Plan approval on 8/18, pending testing with [the Fire and Life Safety Officer (FLSO)] of [temporary] unit, temporary Generator first tested in December, pending a successful test. Warning: The items listed below are currently outstanding on this project and require resolution... Failure to clear these items is considered failure to construct the project in accordance with the approved construction documents and is a violation of Title 24, California Administrative Code Section 7-143 and will prevent HCAI from providing Substantial Compliance, Certificate of Occupancy, and Construction Final. Item #1: Date Added to the Project Record: 08/01/2023: S221869-19-00: ELEC: For KEY NOTE 2: provide 3/4"C, 3#8 & 1#8E.G. minimum. [CEC 300.3(B), CEC 200.4(A)]." d) The report dated 12/6/2024 indicated, "Project has not progressed beyond 10 percent per year. Progress indicated as 30 percent 10/18/2023. Current reporting is 30 percent. Project closure imminent. [California Administrative Code (CAC)] 7-129 time limitations. (d) If the work of construction is suspended or abandoned for any reason for a period of one year following its commencement, the Office's approval shall become void. Prior to the approval becoming void, the applicant may apply for one extension of up to one year. The Office may require that the construction documents be revised to meet current regulations before granting an extension. The extensions must be requested in writing and justifiable cause demonstrated. For the purpose of building permit time limitation, a project shall be considered abandoned when the work of construction, if any, performed during any twelve-month period does not result in a minimum of ten percent increase in the overall percentage of construction work for the project based on either its scope or cost and no extension for time has been approved by the office. During a review of the facility's invoice titled, "Invoice #: 25324," dated 10/23/2022, the invoice indicated the vendor conducted an "Urgent after hours installation of a temporary generator due to facility [permanent] generator being stolen." During a review of the facility's invoice titled, "Invoice #: 28169," dated 1/22/2025, the invoice indicated the vendor conducted a "[Temporary] Generator Removal and New [temporary] Generator Installation, Includes the following below: Removal of old [temporary] generator, Includes all material and labor to remove [temporary] generator, includes all material and labor to stage and electrically install new rental [temporary] generator, Includes delivery of Rental [temporary] Generator and Cables." During a concurrent observation and interview on 1/21/2026 at 10:25 AM with the Life and Safety Manager (LSM), Maintenance Director (MSD), and the Environmental Service Technician (EST) at southeast the side of the building inside the fenced area, there was a temporary generator on wheels. The make and model of the generator is Wacker Neuson G20. The LSM stated it is a temporary generator because the main, permanent generator was stolen. The LSM stated that he will show the HCAI permits. During an interview on 1/21/2026, the following was stated: a) At 2:10 PM, the LSM stated that the permanent generator was stolen 10/17/2022. The LSM stated they had a backup temporary generator connected within six hours and contacted HCAI. b) At 2:14 PM, the LSM stated they notified HCAI on 10/18/2022 and HCAI was on site to inspect the new, temporary generator on 10/21/2022. c) At 2:25 PM, the LSM stated he is responsible for overseeing the HCAI projects. d) At 2:30 PM, the LSM stated that they originally replaced the stolen, permanent generator with another, temporary generator that was too big and would not meet HCAI's requirements for five foot of clearance between the temporary generator and the buildings. LSM stated the first temporary generator was operational from 10/2022 to 1/2025 and then replaced with the current, temporary generator (Wacker Neuson). e) At 2:36 PM, the LSM stated that there was no gap of time without backup power except for the initial six hours when the original, permanent generator was stolen. f) At 2:46 PM, the LSM stated that the generator powers the red outlets, twenty five percent of lighting, the nurse call lights, and the fire alarm. g) At 3:10 PM, the LSM stated the previous Maintenance Director noticed the permanent generator was missing the day it was stolen. h) At 3:28 PM, the Director of Nursing (DON) stated that without power, Patient Oxygen concentrators and low air loss mattresses will not work. DON also stated gastrostomy tubes (G-tubes, a surgically placed device used to give direct access to your child's stomach for supplemental feeding, hydration or medicine) will not be powered, so staff will feed the patients manually by gravity. DON also stated oxygen concentrators will be replaced by oxygen tanks and low air loss mattresses will not deflate but won't alternate if there is a loss of power. DON stated they will manually turn patients to prevent bedsores. i) At 4:35 PM, the LSM stated that the reason why the project on the first temporary generator (S221869-19-00) did not meet completion goals was because they (the facility) knew they could not meet the spacing requirements due to the generator being too big and needed to get a smaller generator. During an interview on 1/22/2026, the following was stated: a) At 9:35 AM, the LSM stated that he does not believe they contacted CDPH when they switched from the first temporary generator to the second temporary generator. The LSM also stated that there was no interruption of backup power leading up and during transition of switching generators. b) At 9:55 AM, a verbal request for the facility's evacuation policy and procedure (P&P), relocation agreements with other facilities, resident face sheets, and general maintenance P&P were made. The facility was unable to provide a general maintenance P&P. c) At 10:03 AM, the LSM stated that he left a message for the HCAI Regional Compliance Officer (RCO) regarding the temporary generator switch, the day before the facility switched from the first temporary generator to the second temporary generator, but did not get a response back. LSM stated the generators were swapped because the first temporary generator (Olympian) was not able to meet the five foot building clearance. d) At 10:30 AM, the LSM stated that they did not do an acceptance test for the facility's current temporary generator (Wacker Neuson). e) At 10:40 AM, the LSM stated that they do not have a current approved permit for their temporary generator that is currently being used. f) At 10:45 AM, a request for the facility's current temporary generator's two-hour load bank test was made. g) At 12:19 PM, the LSM stated that the facility does not have a two-hour load bank test for the facility's current temporary generator (Wacker Neuson). During a review of HCAI Report Center titled, "Projects By Facility, Facility: 22134 - Royal Gardens Healthcare," undated, the report indicated that the facility did not have any open projects regarding the installation of a temporary generator. The report also indicates that the facility's last temporary generator replacement was Closed Administrative on 10/24/2022. The report also indicates another temporary generator installation Closed Non-California Building Standards Commission (CBSC) Compliant on 1/31/2024. The report also indicates an emergency generator project Closed Inactive on 1/3/2025. During a review of the facility's P&P titled, "Power Outage / Loss of Electrical Power Policy," undated, the P&P indicated, "To ensure the health, safety, and welfare of all residents during a loss of electrical power, in compliance with California Code of Regulations, Title 22, including emergency preparedness and facility operation requirements... The facility shall maintain procedures to safely manage power outages, including temporary or extended loss of electricity, and shall take all reasonable steps to protect residents from harm, disruption of care, or unsafe conditions... The facility shall ensure the following are maintained at all times: Emergency lighting (battery-operated or generator-powered) ... If the facility has backup power, it shall be used in accordance with manufacturer and safety guidelines" During a review of the HCAI Project Application Summary form titled, "Project number S250006-19-00," the application summary form indicated the project was closed due to project being inactive. Project start date states 1/3/2025 and project close date states 11/14/2025. During a review of the work order invoice titled, "Invoice 28169," The invoice indicated that the temporary generators were exchanged on 1/22/2025. The facility failed to obtain the required substantial compliance from HCAI during the installation of a temporary emergency generator and associated electrical alterations. As a result, 41 residents were placed at risk of accidents from the unauthorized installation of the temporary emergency generator system.