Facility Evaluation Report

On October 7, 2025, at 9:00 a.m., an in-person Informal office meeting was conducted. In attendance is LPM /Eva Alvarez, LPA/ Alfonso Iniguez, Don McDonald/Administrator, and Robert Esquer/Maintenance Director. The purpose of this meeting was to discuss the state of the facility's water heating system and Title 22 reporting requirements.

On 9/27/25, the department conducted an Annual visit and found the facility water temperatures registered at approximately 90 degree Fahrenheit on the 6th, 5th and 4th floor due to the circulation pumps failing to operate properly. The facility was issued a citation and civil penalties for the deficiency. Administrator/ MacDonald stated the problem was identified prior to the licensing visit on 9/27/25; however, it was not reported to licensing as the facility focused on the repairs needed.

Administrator/MacDonald stated a request for repairs was made to the corporate office, after the issue was identified, and an approval was provided. On 10/3/25, the repair of the circulation pumps occurred and the issue resolved. The citation issued was cleared on 10/7/25 during this office meeting.

During this meeting LPM/Alvarez conducted a brief overview of Title 22 reporting requirements as the facility failed to report the circulation pumps not operating properly. LPM/Alvarez informed the Administrator that a citation would be issued and civil penalties assessed as the reporting citation is a repeat violation within the last 12 months. Administrator/ Mac Donaldson stated a plan of correction would be submitted to the department by 10/13/25. The plan will ensure that reportable issues will be reported to licensing per Tile 22 regulations.

The meeting concluded at 10:00 am. An exit interview conducted, and the report provided to Don McDonald/Administrator.