Health inspection·February 26, 2026

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report to the Department (California Department of Public Health) within 24 hours, a fire incident from a burnt  HVAC (Heating, Ventilation, and Air Conditioning; a comprehensive system designed to regulate indoor temperature, humidity, and air quality) unit filter on 1/10/2026.   This failure had the potential for the fire to not be investigated which could place residents, visitors, and staff at risk for smoke inhalation (damage caused to the respiratory system, airways, and lungs by breathing in harmful combustion products [smoke] from fires) which could result in respiratory irritation, including coughing, shortness of breath, and complications such as airway swelling, reduce amount of oxygen to the body, hospitalization, and death.   During a telephone interview on 1/13/2026 at 5:33 PM with the Director of Nursing, the DON stated Registered Nurse 1 (RN 1) notified him on  1/10/2026 at 10:59 AM that they had noticed smoke inside the facility along the hallway leading to the facility lobby. The DON further stated paramedics (healthcare professionals trained to provide emergency medical care to individuals who are injured or ill ) were in the facility to respond to a 911 (emergency telephone number to quickly connect callers to emergency services) call for a resident with change of condition when the paramedics noticed smoke in the building. The DON also stated the smoke detector did not alarm. During an interview on 1/14/2026 at 11:42 AM with Maintenance Director (MD), MD stated on 1/10/2026 at 11:15 AM, Maintenance Staff (MS) called and informed him that there was smoke inside the facility. Later, on 1/10/2026 at 11:26 AM, MS also reported that there was a smell of smoke in the hallway, which was coming from the ceiling vent connected to HVAC unit 15. During a concurrent observation and interview on 1/14/2026 at 11:47 AM with the facility’s Administrator (ADM), the HVAC unit 15’s filter was observed to be partially burnt. The ADM stated the filter caught fire while workers were torching (to deliberately set something on fire) the facility’s roof. The ADM further explained that the torch used to patch the roof ignited in flame, causing the HVAC filter to catch fire, and the smoke immediately travelled down the vent. During an interview on 1/14/2026 at 1:55 PM with LVN 3, LVN 3 stated that on 1/10/2026, he smelled a faint odor of some type of fumes in the hallway. During an interview on 1/14/2026 at 2:13 PM with MS, MS stated that on 1/10/2026 at 10:58 AM, he received a call from the facility’s receptionist reporting that the facility smelled of smoke. MS stated that he briefly went inside the facility, then went up to the roof and saw that the filter of HVAC unit 15 was partially burnt. MS added that the workers on the roof told him the filter had caught fire. During an interview on 1/14/2026 at 2:56 PM with the Activity Director (AD), AD stated that on 1/10/2026, before 11 AM, she saw haze in the hallway and heard staff saying there was smoke. During an interview on 1/14/2026 at 5:15 PM with the DON, the DON stated that on 1/10/2026 at 10:59 AM, RN 1 called him to report that there was smoke inside the facility. The DON stated that having smoke inside the facility is not safe for residents and added that smoke inhalation is harmful to anyone because it can cause shortness of breath, which may lead to hospitalization for residents with underlying respiratory conditions. The DON stated RN1 should have called 911 and the Department to report the incident of smoke/fire in the facility because it was an unusual occurrence A review of facility’s Policy and Procedure (P&P) titled, “Unusual Occurrence Reporting,” dated September 2023, indicated as required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of the residents, employees or visitors. It indicated that the facility will report the following events to appropriate agencies a. Earthquakes, floods, gas explosions, severe fires, power outages other calamities that damage the facility or threaten the welfare, safety, or health of residents, employees, or visitors. Unusual occurrences shall be reported to appropriate agencies as required by current law and /or regulations within 24 hours of such incident or as otherwise required by federal or state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within 48 hours of reporting the event as required by federal and state regulations. The facility failed to report to the Department within 24 hours, a fire incident from a burnt  HVAC unit filter on 1/10/2026.   This failure had the potential for the fire to not be investigated which could place residents, visitors, and staff at risk for smoke inhalation which could result in respiratory irritation, including coughing, shortness of breath, and complications such as airway swelling, reduce amount of oxygen to the body, hospitalization, and death. The above violation had a direct or immediate relationship to the health, safety, or security of the residents, visitors, and staff.