Based on observation, interview, and record review, the facility failed to maintain the HVAC (Heating, Ventilation and Air Conditioning; The HVAC system is essential for maintaining environmental temperatures within safe and acceptable ranges. This includes the air conditioning unit as well as the ventilation systems) system in a safe operating condition. Two of three air conditioning compressors (mechanical devices that maintains the facility at a cool, comfortable temperature ranging from 71 to 81 degrees Fahrenheit [ F, unit of temperature]) were malfunctional and not maintaining the facility at a cool, comfortable temperature for 79 of 79 residents residing in the facility. As a result, residents' room temperatures were hot and uncomfortable with temperatures ranging from 86-89 F. …
F908 citations in California
Equipment in safe condition · Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F908 more often than its own record predicts
1.76 times the share F908 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F908.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F908 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to ensure the safe operation of a Low Air Loss mattress (LAL - is an air mattress covered with tiny holes so that the user floats on a soft cushion of air) and the use of full side rail up when bathing and repositioning one of three sampled residents (Resident 1) in bed to prevent accident with injury. Resident 1 had functional [CONDITION(S)] (loss of muscle function and strength on four extremities), was overweight, and had upper bed rails up (towards the head of the bed). …
Based on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. * The facility failed to ensure the ice machine was not cleaned and sanitized according to the manufacturer's instructions. This failure had the potential for the essential equipment to not function in the way they were intended and in turn cause contamination of food, leading to illnesses for the residents. Findings: Review of the facility's matrix (undated) showed 63 residents consumed food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.01% | 2.17× |
| 2024 | 0.84% | 1.89× |
| 2025 | 0.80% | 1.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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