DEVONSHIRE ELDERLY CARE

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that the medication administration records (MARs) for the residents were not properly documented. The morning and afternoon medications for (2) residents were administered by S1 for 07/31/2026, but the record was not initialed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2026 Plan of Correction Administrator to ensure that the administered medications to all the residents shall be properly documented in the Medication Administration Record (MAR). Administrator to re-train staff regarding proper documentation and send an in service training log to LPA/CCLD by POC due date.

Official classification

Type B

Official code

1569.626(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on (interview) (record review), the licensee did not comply with the section cited above in that Staff #1 completed (6) hours of dementia training on 02/21/2025, however there was no proof of training for the remaining (6) hours of which shall be completed within (4) weeks of employment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction Administrator to ensure that staff have the required training and send a copy of the remaining (6) hours of dementia training certificate to LPA/CCLD by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area that showed there was water damage, leaks to the ceiling which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/administrator shall plaster/paint, the ceiling where the water/hole damage was located. The licensee/administrator shall send a picture/repair paperwork to the LPA. POC due date: 03/19/25.

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of mold/mildew which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator/Licensee will need to send the removal/cleaning of the mold/mildew from behind the refrigerator and flooring in resident's room. POC Due Date: 09/18/24

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(a)

Regulation authority

CCR

What the official deficiency says

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by Based on the observation and record review the licensee did not comply with the section cited above in handling of 1 out 5 resident's property which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator/Licensee will reimburse resident/former resident of all personal items POC Due Date: 10/02/24

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure four (4) out of four (4) damages at the facility to be in repaired at all times which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/administrator shall repair the ceiling panel in the kitchen, the fireplace covering to be attached and the broken sliding door in the resident's room, the broken door to the entrance/exit of the facility by POC due date: 10/23/24. The licensee/administrator shall send a picture/repair paperwork to the LPA.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

87458(b)(1)-The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis/secondary diagnosis,...results of an examination for communicable tuberculosis, other diseases...This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of six (6) residents to have their Physican's Report and tuberculosis paperwork which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/administrator shall have and retain the proper paperwork for each resident for three (3) years and send copy of tuberculosis to the LPA by POC due date: 10/23/24

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of five (5) staff had a health screening which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/administrator shall have and retain the proper paperwork for each staff and send a copy of health screening to the LPA by POC due date: 10/23/24

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Clearance 87355(e)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Licensee failed to obtain criminal clearance/background association for an indvidual that is currently working as a staff which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

LPA requested adminstrator to remove the individual from the facility area as soon as possible. Within 24 hours licensee must inform RO that the individual is removed and will not return to facility without criminal record clearance and association. A $500.00 civil penalty will be assessed at the time of this visit.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:This requirement is not met as evidenced by: Based on the observation and record review, the licensee did not comply with the section cited above in regards to the garage being converted into three (3) living areas which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administration/Licensee will need to contact the fire department to receive immediate fire clearance. POC 09/18/24

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:This requirement is not met as evidenced by: Based on the observation, interview and record review, the licensee did not comply with the section cited above in submitting an application for the conversion of the garage into three (3) separate living units which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee will submit a written declaration explaining the steps that they are going to take to complete the project. POC 09/18/24

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit.This requirement is not met as evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of contruction-removal of a garage and new construction which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator/Licensee will need to send the building permit to LPA Sauced0. POC 09/18/24

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding any resident injuries/hospitalizations while in care, police reports POC 09/18/24

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Clearance 87355(e)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Licensee failed to obtain criminal clearance/background for the individual that is living in one (1) of the three (3) living areas attached to the above facility which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

LPA requested adminstrator to remove the individual from the facility area as soon as possible. Within 24 hours licensee must inform RO that the individual is removed and will not return to facility without criminal record clearance and association. A $500.00 civil penalty will be assessed at the time of this visit.

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions…and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPA Spaeth’s and LPM Agard’s observations, a kitchen knife was left on the kitchen counter which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

LPA Spaeth and LPM Agard observed the caregiver locked the knife in a kitchen drawer.

Deadline recorded: Mar 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review, the licensee did not comply with the section cited above in two out of three persons which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/11/2024 Plan of Correction Licensee/Administrator will email certification of CPR/Firstaid of all staff currently working at the facility.

Official classification

Type A

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of one objects which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/11/2024 Plan of Correction Licensee/Administrator will take a picture of the removal of the SPA/Jacuzzi from the facility or/and or take a picture of a fence and it being locked and secured inaccessible to the residents.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Based on document review & observation, the Administrator didn’t comply with section cited above. On three separate visits, the Administrator was not present a sufficient number of hours to permit adequate attention to the management and administration of the facility resulting in multiple deficiencies & compliance issues. This an poses an immediate health and safety risk to residents in care.

Official plan of correction

LPAs obtained copy of updated LIC500 which was submitted to assigned LPA on 3/20/22. LIC500 reflects updated Administrator hours.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

CCR

What the official deficiency says

Deficiency narrative not available.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on food inspection conducted by Ombudsman on 3/10/22 it was observed that the facility kept expired eggs and rice without an appropriate cover in the refrigerator. Moreover on 3/16/22, LPAs observed 3 refrigerators with crumbs, stains and liquid spills from frozen meat. This poses a potential health and safety risk to the residents in care.

Official plan of correction

Based on LPAs observation, this deficiency has been cleared as of today's visit.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Water temperature meaured at 142.7 degree F. Deficient Practice Statement Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/18/2022 Plan of Correction Licensee will need to submit daily water temperature log for 3 weeks and adjust the hot water temperature to meet regulations by the POC due date.

Official classification

Type A

Official code

87311

Regulation authority

CCR

What the official deficiency says

All facilities shall have telephone service on the premise This requirement is not met as evidenced by: LPA Martinez attempted to dial out using the land line but was not operational. Phone monitor displayed " No Line " Deficient Practice Statement Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/18/2022 Plan of Correction Licensee is to add a working telephone to the facility that can be used by residents. Proof of installed land line should be email with facility phone number.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: One out of three bathrooms did not have a non-skid mat. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2022 Plan of Correction Licensee is to purchase a non-skid mat for restroom place inside shower by the POC due date.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license including the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: Based on LPAs observation on an annual visit on 3/10/22, the licensee did not comply with the section cited above as 7 residents were living at this facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

There are now only six (6) residents in care. Plan of correction has been cleared as of today's visit, 3/16/2022. .

Deadline recorded: Mar 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on LPA observation and interviews, the licensee failed to provide sufficient staff for residents in care. There was one (1) staff member for six (6) residents in care.

Official plan of correction

The Administrator shall initiate the process to hire additional staff. Proof of hiring additional staff and updated LIC500 shall be submitted to LPA Martinez via e-mail by 3/18/2022.

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

87705 (f)(1)(2) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPAs observations, the Administrator did not ensure that medications, tools, and cleaning supplies were inaccesible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care due to dementia residents in care.

Official plan of correction

Administrator shall ensure that medications, tools, cleaning supplies and other dangerous items shall remain locked and inaccessible to clients in care. Administrator shall conduct in house training with all staff and copies and photos shall be submitted to LPA Martinez by 3/20/22.

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, interview and record review, the Administrator failed to provide two (2) out of sixe (6) resident records. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator will provide proof of resident files/records for 2 out of the 6 residents. Administrator is to email proof of records/documents to LPA by 3/20/2022.

Deadline recorded: Mar 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

78506(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by: Based on observation, the Administrator did not ensure that resident records remain confidential as they were located in a shared bookshelf in one of the bedrooms. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator is to desginate a confidential space for record keeping such as a locked storage cabinet for confidential record keeping. Proof will be submitted to LPA by 3/20/2022.

Deadline recorded: Mar 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observation during the annual conducted concurrently today, bathrooms were observed to be unsanitary, one bedroom had a strong urine smell, and the refrigerators were contaminated with old food spills including old packaged meat liquids.This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator is to hire a outside company or a weekly housekeeper. Administrator will send documentation proof that indicates they have hired housekeeping services.

Deadline recorded: Mar 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on LPA observation during the annual conducted concurrently today, two window screens are in disrepair, facility has large cracks in walls, kitchen cabinets are in disrepair, one fire alarm detector is in disrepair, staff bedroom door is broken, staff bedroom wall has a hole, and outlet covers are missing and have exposed wires in one of the bedrooms. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator is to hire a repair company to come and fix/repair items mentioned in today'a annual and complaint report. Photo proof of repair or intent to repair will be submitted by the POC date.

Deadline recorded: Mar 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license including the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations the licensee did not comply with the section cited above as 7 residents were observed living at this facility which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalties 1548(c) Notwithstanding Section 1534, the department shall assess an immediate civil penalty of five hundred dollars and a one hundred dollar ($100) per day per violation for any of the following serious violations: (1) (A) Fire clearance violations, including, but not limited to, over capacity.

Official plan of correction

POC Due Date: 03/11/2022 Plan of Correction Administrator will put into writing her plan on how she will safely relocate the resident in care and remain in compliance and submit to the LPA by the POC date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. (e) ...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by allowing someone to rent and live in the converted garage which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2022 Plan of Correction The administrator notified the person in the backyard that they are not to be in the garage until they have been finger print cleared. The administrator will also submit a facility sketch that outlines that the garage is now an apartment. An immediate civil penalty of $500 assessed for zero tolerance violation.

Official classification

Type A

Official code

87307(e)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Facilities providing services...physical or mental disabilities... assure the inaccessibility of ... swimming pools,... water, when not in active use by residents... through fencing...means. This requirement is not met as evidenced by This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by making the hot tub inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2022 Plan of Correction The administrator will drain the water, cover or fence the hot tub and submit photos to the LPA as POC. immediate civil penalty of $500 assessed for zero tolerance violation.