F0908

D

Lack of Documentation for HVAC Preventive Maintenance by Outside Contractor

Alhambra, California Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain documented evidence that its Heating, Ventilation, and Air Conditioning (HVAC) system was being serviced and maintained by an outside HVAC contractor to ensure it was safe and in good working condition. Review of the undated floor plan showed 54 resident rooms across two floors, and a census report showed 95 residents in the facility with a bed capacity of 99. During interviews and record review, the Maintenance Supervisor was unable to provide any logs, records, or reports of semi-annual HVAC maintenance visits by the outside company since he had been employed in the role. He acknowledged that he did not have a log or record of maintenance visits and that he should have been tracking HVAC maintenance by outside companies to monitor compliance and ensure the system remained safe and functional.

Further interviews with the Administrator confirmed that the facility did not have copies of HVAC maintenance visit records on hand to verify that the system was being checked and maintained to keep temperatures within normal ranges. The Administrator stated that documentation of maintenance services from outside companies should be available to ensure the HVAC system was being checked, safe, and working properly, and noted that a request for past service records had only been sent on the day of the survey. Review of the facility’s “Maintenance Service” policy and procedure, dated 2001, indicated that the maintenance director (maintenance supervisor) is responsible for maintaining records and reports of work order requests and maintenance schedules, and that these records are to be maintained in the maintenance director’s office. Despite this policy, the required HVAC maintenance documentation was not available during the survey.