Health inspection·March 17, 2026

Title 22 Division 5 Chapter 3 Article 2 License 72205. Safety, Zoning and Building Clearance. (b) The licensee shall maintain the skilled nursing facility in a safe structural condition. If the Department determines in a written report submitted to the licensee that an evaluation of the structural condition of a skilled nursing facility building is necessary, the licensee may be required to submit a report by a licensed structural engineer which shall establish a basis for elimination or correcting the structural conditions which may be hazardous to occupants. The licensee shall eliminate or correct any hazardous conditions. Title 22 Division 5 Chapter 3 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 3/3/2026 at 11:10 AM, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint 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) prior to the removal of a portion of the shared wall between two distinct rooms. As a result, 40 residents were placed at risk of harm from the potentially compromised structural condition of the ceiling assembly (multi-layered construction system separating floors or covering roof structures, designed for fire resistance, soundproofing, and structural support) as a result of the unauthorized wall removal. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 3/3/2026 at 11:41 AM with the Medical Records Director (MRD), the MRD stated that she has worked at facility for approximately six years. The MRD stated the wall in the therapy gym was removed sometime last year [2025], between 7/2025 and 10/2025. The MRD stated the therapy gym used to be two distinct rooms – one used for physical therapy (therapy to treat injuries, illnesses, and chronic conditions and to improve movement, relieve pain, and restore function) and the other used for occupational therapy (therapy to help individuals regain, develop, or maintain the skills needed for daily living and working following illness, injury, or disability) – each with their own entrance. The MRD stated that facility management removed the wall to give more space and for the residents to have access to both occupational therapy and physical therapy without having to go around the facility to get to the other side. During an interview on 3/3/2026 at 11:58 AM with the Physical Therapy Assistant (PTA), the PTA stated that she has worked at the facility for approximately 15 years. The PTA stated the wall of the therapy gym was removed approximately two to three years ago, and the reason was to make a bigger space. The PTA stated the previously distinct rooms were used for physical therapy and occupational therapy separately. During a concurrent observation and interview on 3/3/2026 at 12:20 PM with the Maintenance Supervisor (MS) in the therapy gym, the section of the room designated for physical therapy was measured by the MS. The MS stated the measurements taken to be 22 feet (ft) by 17 ft and an additional area of nine ft by five and a half ft for a total measurement of approximately 424 square feet (sq ft). During a concurrent observation and interview on 3/3/2026 at 12:25 PM in the therapy gym with the MS, the section of the room designated for occupational therapy was measured by the MS. The MS stated the measurements taken to be approximately 21 ft by 22 ft. The MS stated approximately 40 sq ft from the total area was subtracted to account for the diagonal layout of the room. The MS stated the total measurement was approximately 422 sq ft. During an observation on 3/3/2026 at 12:35 PM with the MS in the therapy gym, there were two cutouts (hollow sections where a section of the wall was removed) with a small piece of the wall left as a support column in between the two cutouts. This cutout section delineated the two sections of the room (physical therapy and occupational therapy). During interviews on 3/3/2026 with the Executive Director (ED) and the Director of Operations (DIR), the following were stated: A. At 1:07 PM, a facility floor plan more than two years old was requested. The ED stated he will look into his files to see if he can find a copy of a floor plan that is more than two years old. B. At 1:08 PM, documentation including the scope of work for the wall removal, other relevant wall removal documents such as vendor quotes and invoices, HCAI documentation or correspondences, and documentation of notification to the Department regarding the wall removal was requested. The ED and DIR stated that they do not have the requested documentation because the wall was not removed during the tenure of the current ownership. C. At 1:10 PM, the DIR stated that the only correspondence they have with HCAI regarding the wall removal will be from today’s (3/3/2026) investigation by the HCAI Compliance Officer (HCAI CO). D. At 1:23 PM, the DIR stated that the current ownership of the facility began on 4/1/2024. E. At 1:24 PM, documentation showing the change of ownership date was requested. The DIR stated he will get the documentation. During an interview on 3/3/2026 at 3:20 PM with the Certified Nurse Assistant (CNA), the CNA stated that she has worked approximately 10 years within the facility with different companies. The CNA stated the wall in the therapy gym was removed less than one year ago, sometime between 7/2025 to 8/2025. The CNA stated one room was used for occupational therapy and the other room was used for physical therapy, prior to the wall removal. The CNA stated she thinks the wall removal occurred during the current ownership. During an interview on 3/3/2026 at 3:31 PM with the Licensed Vocational Nurse 1 (LVN 1), the LVN 1 stated that she has worked at the facility since 2018. The LVN 1 stated she does not remember dates but stated at one point there was a wall that divided the two sides of the therapy gym. During an interview on 3/3/2026 at 3:37 PM with the Licensed Vocational Nurse 2 (LVN 2), the LVN 2 stated that she has worked at the facility since approximately 1/2025. The LVN 2 stated the current ownership had already taken over when she started working at the facility. The LVN 2 stated there was a wall in the therapy gym when she started working at the facility, and the wall was later removed. During a concurrent observation and interview on 3/3/2026 at 3:42 PM with the MS in the therapy gym, the MS measured the cutouts created from the removal of the wall. The MS stated the smaller cutout measured 91 inches (seven ft and seven inches) in height by 55 inches (four ft seven inches) in width. The MS stated the larger cutout measured 91 inches (seven ft seven inches) in height by 137 inches (11 ft five inches) in width. The MS stated the entire length of the wall space measured 268 inches (22 ft and 4 inches) in width. During an interview on 3/3/2026 at 3:53 PM with the ED, the ED stated that he does not have a building plan, a floor plan of the facility that is older than two years, or any other HCAI documentation aside from the report received today titled, “Construction Advisory Report – Investigation.” During a concurrent interview and record review on 3/3/2026 at 4:01 PM with the ED, the HCAI report titled, “Construction Advisory Report – Investigation,” dated 3/3/2026, was reviewed. The HCAI report indicated, “It appears the wall was opened up at some point to allow the rooms to be open to one another. It is advised to retain a Design Professional to confirm that making the openings in the wall did not compromise the structural integrity and/or wall rating.” The ED stated that they have a structural engineer, who is the facility’s maintenance consultant, that will come and look at the structural integrity and safety of the wall area. During a review of the facility’s CDPH license, the license indicated the current ownership became effective on 4/1/2024. During a review of the HCAI Report Center (public website that displays all HCAI projects for a listed facility) as of 3/3/2026, there were no open or closed projects associated with the removal of the wall in the therapy gym. During a review of the facility’s policy and procedure (P&P) titled, “Building Systems General Maintenance Inspection,” undated, the P&P indicated, “It is the policy of this facility to maintain building systems in good working order, inspecting them at intervals which comply with state, federal and company standards to repair as necessary.” The facility failed to obtain the required written authorization, building permit, construction approval, and attain substantial compliance from HCAI prior to the removal of a portion of the shared wall between two distinct rooms. As a result, 40 residents were placed at risk of harm from the potentially compromised structural condition of the ceiling assembly as a result of the unauthorized wall removal. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.