Health inspection·January 29, 2026

South Pasadena Care Center The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: 2716351 Complaint Survey ID: 1E1185-L1 Representing the Department: HFE I #48987 State Citation B was written 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. 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. On 1/14/2026 at 9:50 a.m., the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate an entity reported incident 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 for maintenance of heating, ventilation, and air conditioning (HVAC) units. The facility also failed to notify CDPH in writing within five days of the commencement of the roof repairs and maintenance of HVAC units. As a result, 152 residents were placed at risk of accidents from the unauthorized roofing repairs and maintenance of HVAC units. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 1/14/26 at 9:50 a.m. with the Administrator (ADM) and the Maintenance Supervisor (MS) in the Conference Room, documents were requested regarding the scope of work for any roof/HVAC repairs, HCAI documentation or correspondence related to roof repairs, and documentation or correspondence from the Inspector on Record (IOR, independent health care facility inspectors certified by HCAI) related to roof repairs. The ADM stated the facility does not have HCAI documentation related to roof repairs and they did not notify CDPH of the roof repairs. During an observation on 1/14/26 at 10:58 a.m. with the MS on the roof of the facility, there were rubber roofing rolls (flat sheets made of rubber to create a waterproof barrier on the roof) and new roofing installed on the north side of the building. The roof on the north side of the building was a brighter white color and appeared cleaner than the other roofing material on the south side of the building. The parapets (a low protective wall along the edge of a roof) on the north side of the building were also stripped of waterproofing material and the plywood frames of the parapets were exposed. During an interview on 1/14/26 at 11:01 a.m. with the MS on the roof of the facility, the MS stated that the vendor moved HVAC unit #15 out of the way to repair the roof underneath it. The MS stated the vendor was only working on the area underneath HVAC unit #15 on 1/10/26 and it was approximately five feet (ft) by five ft in size that was repaired. The MS stated the vendor came back out on Monday, 1/12/26, to continue working on the sides of the roof (parapets). During an interview on 1/14/26 at 11:05 a.m. with the MS on the roof of the facility, the MS stated that the repairs of the roof started because when it rained a lot recently, the facility had a leak in the roof. The MS stated they did not know where the leak was coming from, so they started the project to repair the roof on Tuesday, 1/6/26. The MS stated the repairs were only patches and not the entire roof, that the roof was repaired a few years ago but he was not working at the facility during that time. During an interview on 1/14/26 at 11:46 a.m. with the ADM and MS, the ADM stated the HCAI FREER Manual (A Guide for Field Review [FR], Excluded [E] from OSHPD Plan Review, and Expedited Review [ER]) indicates that any roofing repairs less than 300 sq ft does not require an HCAI permit, so he did not think they needed to notify HCAI. During an interview on 1/14/26 at 12:05 p.m. with the MS, documentation such as invoices or reports was requested from the vendor regarding the roof repairs. During an interview on 1/14/26 at 12:17 p.m. with the ADM, the ADM stated the facility noticed the roof started leaking when the rain started in 10/25 and 11/25. During an interview on 1/14/26 at 12:24 p.m. with the HCAI Compliance Officer (HCAI CO) in the corridor next to Room 301, the HCAI CO stated that he went on the roof and noted the whole north side of the roof had been repaired, and that some HVAC units needed to be remounted (secured to the roof). The HCAI CO stated he saw roof leaks inside the facility, like the one next to Room 301. The HCAI CO stated he touched the ceiling next to Room 301 and it was soft to the touch. The HCAI CO stated he needs to research if the facility had an HCAI project for the roof that was repaired in the past. The HCAI CO stated if the facility did not have an HCAI project, the facility would need to open a new project for the roof and for remounting the HVAC units. The HCAI CO stated there was also some ponding of water on the roof in small areas that need to be repaired. The HCAI CO stated he will write the report and it will include all his findings. During a concurrent interview and record review on 1/14/26 at 2:07 p.m. with the Maintenance Assistant (MA), the facility map (undated) was reviewed. The MA stated the repairs for the roof started last week Tuesday (1/6/26), and that the vendor repaired the whole north side of the building. The MA stated he cannot approximate how large an area they repaired. The MA pointed to the facility map to show the scope of the roof repairs and outlined an area from Room 211 to the Kitchen and Main Dining Room. During a concurrent observation and interview on 1/15/26 at 9:08 a.m. with the MS on the roof of the facility, the HVAC units were observed. The MS stated that all HVAC units are connected to a gas line to provide heat to the facility. During concurrent observations and interviews on 1/15/26 with the MS on the roof of the facility, the following were observed: a. At 9:10 a.m., HVAC unit #17 was sitting on top of wooden beams and was not secured to the roof. The MS stated that the HVAC unit was not secured to the roof and that in an earthquake, it can topple over. b. At 9:11 a.m., HVAC unit #16 was placed on top of two concrete parking stop blocks (barriers installed at the front of parking spaces to prevent vehicles from driving too far forward). The MS stated the HVAC unit was placed on top of the parking stop blocks and was not secured. c. At 9:13 a.m., HVAC unit #15 was sitting on top of a wooden beam. The MS stated the HVAC unit was not secured to the roof. d. At 9:16 a.m., HVAC unit #14 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. e. At 9:17 a.m., HVAC unit #13 was sitting on top of a wooden beam. The MS stated the HVAC unit was not secured to the roof. f. At 9:19 a.m., HVAC unit #12 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. g. At 9:20 a.m., HVAC unit #21 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. h. At 9:21 a.m., HVAC unit #20 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. i. At 9:22 a.m., HVAC unit #19 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. j. At 9:22 a.m., HVAC unit #18 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. k. At 9:24 a.m., HVAC unit #11 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. l. At 9:24 a.m., HVAC unit #10 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. m. At 9:26 a.m., HVAC unit #9 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. n. At 9:29 a.m., HVAC unit #8 was sitting on top of two concrete parking stop blocks. The MS stated the HVAC unit was not secured to the roof. o. At 9:31 a.m., HVAC unit #7 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. p. At 9:34 a.m., HVAC unit #6 was sitting on top of two concrete parking stop blocks. The MS stated the HVAC unit was not secured to the roof. q. At 9:35 a.m., HVAC unit #5 was sitting on top of two wooden beams. The MS stated the HVAC unit was not secured to the roof. r. At 9:35 a.m., HVAC unit #4 was sitting on top of two wooden support beams. The MS stated the HVAC unit was not secured to the roof. s. At 9:40 a.m., HVAC unit #1 was sitting on top of two wooden support beams. The MS stated the HVAC unit was not secured to the roof. t. At 9:40 a.m., HVAC unit #2 was sitting on top of a wooden support beam. The MS stated the HVAC unit was not secured to the roof. During an interview on 1/15/26 at 9:47 a.m. with the ADM and MS, the specification sheet/handbook for the facility’s HVAC units was requested. During a concurrent interview and record review on 1/15/26 at 10:27 a.m. with the ADM, the facility’s invoices from their roofing vendor, dated 9/10/25, 10/15/25, and 1/6/26, were reviewed. The invoices indicated that “flat roof repair” of “12 big squares (a roofing square is a standard unit of measurement representing 100 square feet of roof surface, equivalent to a 10-foot by 10-foot area)” was conducted on 9/10/25, “9 big squares” of roof repairs was conducted on 10/15/25, and “10 big squares” of roof repairs was conducted on 1/6/26. The ADM stated the work started in 9/25 to prepare for the rainy season. The ADM stated he was the ADM during the 24/25 rainy season and there were some roof leaks in the facility, so he wanted to prepare for the upcoming rainy season. The ADM stated the date on the invoice is the date that the vendor started the work. The ADM stated HCAI was not contacted for any of the dates on the invoices. During an interview on 1/15/26 at 10:54 a.m. with the ADM, the ADM stated he is responsible for contacting HCAI. The ADM stated it is important to notify HCAI to ensure the safety of the residents. During a review of the HCAI CO report titled, “Construction Advisory Report – Advisory,” dated 1/14/26, the report indicated, “[ADM] met Co in the lobby and walked a few of the interior corridor locations where water intrusion had occurred and stated that the roof patching was part of excluded work and he did not know he needed to contact HCAI CO. CO noted that several of the areas are still damp and soft to the touch and expressed concerns for mold growth.” The report also indicated, “Walked the roof areas and there are locations of ponding water and new roofing on north half of the building. No projects have been opened for the reroofing and the patching per the FREER manual is limited to 300 square feet. A roofing project will need to be opened to mitigate the unauthorized construction. The building permit should include anchorage of the HVAC units that have all been set on plank, block, and/or curbs without anchorage to the structure.” Further review of the HCAI CO report titled, “Compliance Officer – Field Visit Report,” dated 1/14/26, the report indicated, “Noted roofing ongoing where facility stated patches being placed. Apparent that the whole north half of the facility has newer roofing that was no permitted work. The newer roofing has several areas of ponding water and leak on the north half of the building as evidenced by the leaks in the corridor areas. Roofing installation has removed HVAC units and did not properly anchor the HVAC units to the structure. Several are sitting on wood blocks, curbs, or combination of materials. Parapets are all currently stripped of waterproofing material and have plywood exposed.” During a review of the facility’s HVAC unit manual titled, “American Standard Package Gas/Electric Convertible Models,” dated 5/91, the manual provides illustrations on page 30 and 31 under, “Dimensional Data,” indicating how the HVAC unit should be properly mounted on the roof. During a review of the facility’s policy and procedure (P&P) titled, “Maintenance Service,” last reviewed 1/25, the P&P indicated, “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 the maintenance personnel include, but are not limited to…Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.” 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 for maintenance of HVAC units. The facility also failed to notify CDPH in writing within five days of the commencement of the roof repairs and maintenance of HVAC units. As a result, 152 residents were placed at risk of accidents from the unauthorized roofing repairs and maintenance of HVAC system units. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.