Health inspection·August 13, 2021

F921 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Title 22 §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. (c) All facilities shall maintain in operating condition all buildings, fixtures, and spaces in the numbers and types as specified in the construction requirements under which the facility or unit was first licensed. §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. The facility made repairs the kitchen ceiling without obtaining the requisite approvals from the authority having jurisdiction [AHJ/Office of Statewide Health Planning & Development (OSHPD, a state agency that reviews and approves plans of construction/remodeling, made to the building to comply with State codes)] and not notifying the AHJ, the OSHPD Fire Marshal’s Office, and the Department of Public Health. During an observation, a piece of cardboard was placed over an opening in the ceiling which was hanging down with white debris falling onto the kitchen's dishwasher and utensils used for the facility’s residents. Failure of the facility to obtain the requisite building permits/construction approval from the OSHPD Fire Marshall prior to starting alterations to repair the leak in the kitchen ceiling had a direct relationship to the health, safety, and security of the residents currently occupying the facility. During the initial kitchen tour observation, on 6/22/21 at 9 a.m., a piece of cardboard was placed over an opening (not measured) in the ceiling which was hanging down with white debris falling onto the kitchen dishwasher and utensils used by facility residents such as drinking cups, pans, and other utensils. During an interview, on 6/22/21 at 9:30 a.m., the Dietary Staff 1 (DS 1) stated the Maintenance Staff 1 (MS 1) had started working to repair the ceiling on the evening of 6/21/21, and MS 1 would complete the work after the kitchen closed in the evening (6/22/21). DS 1 stated there was a leaking pipe above the dishwashing area. During an interview, on 6/23/21 at 9:32 a.m., the Dietary Supervisor (DS) stated not being aware that there was a hole in the ceiling or anything about the repair. During an interview on 6/22/21 at 10:41 a.m., the Administrator stated that it (area of the ceiling opening) was noted, on 6/15/21, that there was, "Moisture around the area." The Administrator added that the Maintenance Supervisor went on medical leave so a part time maintenance personnel was called to start the repair. During this interview, on 6/22/21 at 10:41 a.m., the Administrator stated the facility did not notify this Department or the OSHPD of repairs being done to the leaking pipe. The Administrator stated, "We didn't have to notify the Department or OSHPD because it was an easy fix." During a telephone interview with MS 1, on 6/22/21 at 11:45 a.m., MS 1 confirmed patching a leaking pipe, added some brackets, and covered the ceiling with a piece of cardboard. MS 1 stated he would complete the repair when the kitchen closed for the night. The MS 1 also stated that it (the repair) was, "An easy fix and that there was no need to notify the Department or get a contract." During a telephone interview, on 6/22/21 at 03:04 p.m., the Administrator stated the facility would call OSHPD and get a contractor to repair the plumbing issue. A review of the OSHPD onsite report, dated 6/23/21, indicated the following: a. The pipe was repaired with a metal clamp at two locations. The pipe appears to be a metal (not copper) domestic water line that services the kitchen. b. No inspection of the repair was performed by a Certified Hospital Inspector. c. Appears that the clamps used are not listed, as detailed in California Plumbing Code (CPC, provide minimum standards to safeguard life or limb, health, property and public welfare) 301.2. d. Additionally the repair of the pipe is prohibited per CPC 309.2 and "Concealing Imperfections: It is unlawful to conceal cracks, holes, or other imperfections in materials by welding, brazing, or soldering or by using therein or thereon paint, wax, tar, solvent cement, or other leak-sealing or repair agent." e. As this appears to be a leak/repair made in the domestic water line, chlorination is to be performed per CPC 609.9 and a water potability sample is advised to be taken after the work is inspected and performed. f. Repair of drywall in the ceiling is pending. A review of the OSHPD report, dated 6/23/21, recommended the following: a. Facility to apply for a project, submit plans and commence the plan review, approval and building permit process, in compliance with the California Administrative Code, Section 7-113. b. Section 7-128 specifies that construction or alteration of any health care facility performed without the benefit of approval and/or observation by the Office shall be subject to examination by the Office to assess relevant code. c. Compliance that may include: 1. Review of existing plans; 2. Site visit(s) as necessary to assess the extent of unpermitted work; 3. Inspection of work for the purpose of determining compliance; and 4. Participation in a predesign conference with architects/engineers to resolve code issues relevant to the corrective or remedial work necessary. 5. Fee. The facility made repairs the kitchen ceiling without obtaining the requisite approvals from the AHJ/OSHPD and not notifying the AHJ and the OSHPD Fire Marshal’s Office. During an observation, a piece of cardboard was placed over an opening in the ceiling which was hanging down with white debris falling onto the kitchen's dishwasher and utensils used for the facility’s residents. Failure of the facility to obtain the requisite building permits/construction approval from the OSHPD Fire Marshall prior to starting alterations to repair the leak in the kitchen ceiling had a direct relationship to the health, safety, and security of the residents currently occupying the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.