Health inspection·July 12, 2024

California Code of Regulations (CCR), 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 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. § 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 6/27/2024 at 9:11 a.m., an unannounced visit was conducted at the facility. The facility failed to obtain requisite permits for the installation of a temporary emergency power generator, due to the non-operational/failure of the permanent emergency power generator. This deficient practice has the potential for this department to be unaware of any hardships experienced by the facility and the unregulated/unmonitored installation of the generator, which may affect the facility's ability to operate in an emergency power outage, affecting the facility's ability to provide care to patients and rendering all electrical equipment, that are not battery powered, non-functional (such as refrigerators for food and medication, air mattresses, and oxygen therapy machines). This failure had the potential to directly affect 139 patients residing in the facility. On 6/27/2024 at 10:03 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MS) and Maintenance Assistant (MA), a temporary mobile generator was installed in the designated Administrator (ADM) parking space adjacent to the Generator/Electrical Panel Room. The MS stated the temporary mobile generator was installed on or around 5/13/2024 because the permanent generator was broken. The MS stated repair of the permanent generator was pending because the generator repair vendor was awaiting delivery of required parts. The MS stated he was unsure whether permits were obtained from the Department of Health Care Access and Information (HCAI, formerly the Office of Statewide Health Planning and Development [OSHPD]. HCAI is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare facilities to comply with State Building Codes). On 6/27/2024 at 10:17 a.m., during a concurrent observation and interview with the MS and MA in the Generator/Electrical Panel Room, the permanent generator was located inside the room and the wires/cables from the temporary mobile generator were connected to the facility switchboard (device that distributes electricity to the building) and the automatic transfer switch (ATS, transfer panel used with a generator to automatically switch between the municipal power supply and the generator in the event of a power failure). The MS stated the permanent generator became inoperable sometime in May of 2024. On 6/27/2024 at 2:23 p.m., during an interview with the MS, the MS stated the facility did not receive approval from HCAI to install the temporary mobile generator. On 6/27/2024 at 2:23 p.m., during an interview with the MS and Director of Staff Development (DSD), the DSD stated the temporary mobile generator was installed prior to last week, on or around 5/13/2024. During a review of the facility's invoice from the generator repair vendor, dated 2/4/2024, the description of "services provided" indicated the repair of minor items, in addition to labor troubleshooting and installations. During a review of the facility's quote/purchase order for the installation and maintenance of the temporary mobile generator, dated and signed on 5/14/2024, the quote/purchase order indicated that the facility approved the installation of the temporary mobile generator on 5/14/2024. During a review of the facility's policy titled, "Maintenance Service," last reviewed on 1/9/2024, the policy 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...Maintaining the fire alarm system and emergency generator system in good working order." During a review of the facility's policy titled, "Emergency Power Generator Maintenance," last reviewed on 1/9/2024, the policy indicated that the "Purpose... [is] To ensure the safety and well-being of residents, staff, and visitors by guaranteeing that the emergency power generator is fully functional and reliable during power outages and emergencies." The policy also indicated, "Procedures...Compliance... [will] Adhere to all federal, state, and local regulations regarding emergency power systems in healthcare facilities." The facility failed to obtain requisite permits for the installation of a temporary emergency power generator, due to the non-operational/failure of the permanent emergency power generator. The above violations had a direct relationship to the health, safety, and security of the residents, staff, and visitors occupying the facility.