Health inspection·February 23, 2026

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 2/10/2026 at 8:08 a.m., 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) for roofing repairs exceeding 300 square feet (sq ft) and failed to submit the required documentation to the HCAI Compliance Officer (HCAI CO) for consultation and approval prior to repairing damaged walls. As a result, 85 residents were placed at risk of accidents from the unauthorized roofing and wall repairs. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 2/10/2026 at 8:18 a.m. with the Director of Staff Development (DSD), documents were requested regarding the scope of work for any wall and roof repairs, and HCAI documentation or correspondence related to any roof repairs. The DSD stated she would go look if the Administrator (ADM) had the documents. During a concurrent observation and interview on 2/10/2026 at 8:54 a.m. with the Maintenance Supervisor (MTS) in Room 201, the wall behind the beds and the ceiling above the beds had different shades of white paint. The MTS stated the repair work was complete and residents were back in their room. The MTS measured the area that was repaired and painted; the MTS stated the wall behind the beds measured five and a half feet (ft) by 13 ft and the ceiling measured six and a half ft by 13 ft. During a concurrent observation and interview on 2/10/2026 at 8:57 a.m. with the MTS in Room 223, the wall behind the beds and the ceiling above the beds had different shades of white paint. The MTS stated the rooms were back to normal use and the residents were back in their room. The MTS measured the area that was repaired and painted; the MTS stated the wall behind the beds measured 9 ft by 14 ft and the ceiling measured 14 ft by 13 ft. During an interview on 2/10/2026 at 9:01 a.m. with the ADM, the ADM stated the facility is currently in the process of transferring ownership. The ADM stated the previous facility owner directed maintenance to apply tar (a thick petroleum-based substance used as a waterproof sealant to repair and patch roofs) on the roof. The ADM stated the current facility owner took over on 10/6/2025. During an interview on 2/10/2026 at 9:05 a.m. with the MTS, the MTS stated, “The facility does not know where the [roof] leak is coming from. Due to the tar buildup throughout the roof, it’s hard to identify where the leaks are coming from. I had to call the remediation company and had to take care of it to not endanger the residents. The wall/ceiling had mold, and I had the company do repairs. The rooms were empty for two weeks and there is no mold, it’s shown on the reports.” During interviews on 2/10/2026 with the ADM, the following was stated: A. At 9:09 a.m., documentation such as invoices or reports from the vendor was requested regarding the wall repairs. The ADM stated he has documentation for the wall repairs and bids from vendors for the roof repairs. B. At 9:14 a.m., the ADM stated the dry wall in Room 201 and Room 223 was checked for mold and asbestos (fibrous materials used in building materials that can cause long-term health effects when inhaled). C. At 9:17 a.m., the ADM stated the repair work was conducted due to water leaks and took place on 1/5/2026. D. At 9:19 a.m., the ADM stated that HCAI was not contacted and that he believes HCAI does not require a permit for mold remediation. E. At 9:20 a.m., the ADM stated he is responsible for contacting HCAI. The ADM stated it is important to notify HCAI to ensure the ongoing safety of the residents and to ensure compliance with code. F. At 9:21 a.m., the ADM stated aside from Room 201 and Room 223, the dining room upstairs had minor fixes in the corner, as shown in the reports. The ADM stated the area was small. The ADM stated CPDH was not notified of the repairs. G. At 9:22 a.m., the ADM was asked about the repair/work conducted on the roof. The ADM stated, “Nothing to the roof, we can’t. We are putting tarps on the roof due to the rain we expect in the next days. This is the only thing we can do. The initial stage is to get HCAI involved, after we get done with getting estimates, which I am currently getting bids. I can show you.” During a concurrent observation and interview on 2/10/2026 at 9:29 a.m. with the ADM and MTS on the roof of the facility, the roof had visible layers of white and black hardened substances throughout. The ADM stated the substance is tar that had been applied throughout the years per the previous facility owner’s instructions. During an observation on 2/10/2026 at 9:35 a.m. with the ADM and MTS on the roof of the facility, there were pipes surrounding the heating, ventilation, and air conditioning (HVAC) unit with visible tar build-up. During interviews on 2/10/2026 with the MTS, the following was stated: A. At 10:10 a.m., the MTS stated he does the roof repair work and consults a specialist at a home improvement store. The MTS stated he purchases either the black or white tar to patch the roof whenever the previous facility owner instructed him to do so. B. At 10:14 a.m., the MTS stated, “The last time I put tar was in April [4/2025], the roof expert told me to put it in the hot time, but all those patched are from years I been putting tar.” C. At 10:17 a.m., the MTS stated the total area of patched roofing is approximately 2,169 sq ft. D. At 10:20 a.m., the MTS stated HCAI was not contacted regarding the roof repairs. E. At 10:22 a.m., the MTS stated the facility noticed the roof started leaking when the heavy rain started in 12/2025 and 1/2026. F. At 10:23 a.m., the MTS stated there is no documentation when the tar was placed on the roof because no work order was filled. The MTS stated he would go to a home improvement store to buy the tar and provide the receipts to the previous facility owner. During a concurrent observation and interview on 2/10/2026 at 10:41 a.m. with the MTS in the Dining Room, there was a visible paint difference on the wall. The MTS pointed to the corner wall and stated this area is where the wall was patched. During a review of the report titled, “Limited Mold Inspection Report,” dated 1/8/2026, the report indicated, “[Vendor Name] conducted a limited mold inspection and assessment at Infinity Care of East Los Angeles, located at 101 Fickett Street, Los Angeles, California 90033. The inspection was performed on January 5, 2026, by…Certified Mold Inspector.” During a review of the report titled, “Post Mold Remediation Report,” dated 1/21/2026, the report indicated, “[Vendor Name] conducted a Post Mold Remediation Inspection (PMI) at 101 S. Fickett Street, Los Angeles, CA 90033, limited to Rooms 223, 201, and the Conference Room.” During a review of the HCAI Report Center (public website that displays all HCAI projects for a listed facility) as of 2/10/2026, there were no open or closed projects associated with the roofing repairs. During a review of the facility’s policy and procedure (P&P) titled, “Maintenance Service,” dated 6/2/2025, “The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.” The P&P also indicated, “Functions of maintenance personnel 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 roofing repairs exceeding 300 sq ft and failed to submit the required documentation to the HCAI CO for consultation and approval prior to repairing damaged walls. As a result, 85 residents were placed at risk of accidents from the unauthorized roofing and wall repairs. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.