Health inspection·June 23, 2023

§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. §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. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. F921 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. On May 24, 2023, at 11:10 AM, an unannounced visit was made to the facility to investigate a complaint regarding physical environment. The facility failed to obtain the necessary permits/construction sign-off final approval from the Department of Healthcare Access and Information ([HCAI] previously known as the Office of Statewide Health Planning and Development [OSHPD]) and failed to notify the Department within five days of commencement for the installation/replacement of: 1. Unpermitted installation of four HVAC (heating, ventilation, and air conditioning) units on the roof 2. Unpermitted replacement of fire sprinkler heads (the components of a water-based fire suppression system where water exits from the pipes to extinguish fires) throughout the facility 3. Unpermitted installation/remodeling of two automatic sliding doors This deficient practice has the potential for fire related accidents and/or the inability of the fire suppression system to properly function due to the incorrect/unregulated installation of the HVAC units, sprinklers, and sliding doors which directly affects the health, safety, and welfare of 86 patients with varying levels of medical and mental conditions. During a concurrent observation and interview on May 24, 2023, at 11:35 AM, with the Maintenance Supervisor (MS), in the lobby, two automatic sliding glass doors were observed in the front and back of the lobby. The MS stated that he was unaware of when the doors were installed since the MS has only been an employee of the facility for the last four months. The MS stated the facility was unaware if the facility had filed permits with HCAI (Department of Healthcare Access and Information - the State agency having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) or if the facility had notified this Department. During a concurrent observation and interview on May 24, 2023, at 11:44 AM, with the MS, on the roof, four HVAC units with the following manufactured dates were observed: AC Unit #4 - May 2022 AC Unit #1 - November 2022 AC Unit #3 - April 2022 AC Unit #6 - November 2022 The MS stated that he was not employed with the facility during the installation of the new HVAC units. The MS also stated that he was unaware if the facility had notified the Department of Public Health and that they were unaware if permits had been filed with HCAI. During a concurrent observation and interview on May 24, 2023, at 11:58 AM, with the MS, new sprinkler heads were observed installed in the hallway adjacent to the kitchen. The MS stated, "They [Quick Response - sprinkler company] are working on changing the sprinkler heads. The company told us that the sprinklers needed to be replaced every 50 years." During a review of "Projects in Closure, Closed Reports" obtained from the HCAI permit portal website, records did not indicate that the facility obtain permits for the two sets of sliding doors in the lobby, the sprinklers, or for the four new HVAC units on the roof. The facility was requested to provide records for the installation of the above items but could not provide proof of permitting. The facility was requested to provide policies for renovations/remodeling, but the Administrator stated in an email, that the facility does not have such a policy. The facility failed to obtain the necessary permits/construction sign-off final approval from HCAI and failed to notify the Department within five days of commencement for the installation/replacement of: 1. Unpermitted installation of four HVAC (heating, ventilation, and air conditioning) units on the roof 2. Unpermitted replacement of fire sprinkler heads (the components of a water-based fire suppression system where water exits from the pipes to extinguish fires) throughout the facility 3. Unpermitted installation/remodeling of two automatic sliding doors The above violations had a direct or immediate relationship to the health, safety, or security of all patients.