Substantial compliance: What is?

According to Title 22, §87101(s)(9), "substantial compliance" means the absence of any deficiencies which would threaten the physical health, mental health, safety and/or welfare of the residents. 

Throughout our reviews, CARR found that "substantial compliance" was a subjective, rather than objective, designation.  This, we concluded, was due to the discretionary nature with which the regulations are enforced.  For example, one Licensing Program Analyst (LPA) may deem a water temperature or food service violation, if corrected at the time of visit, as not worthy of a deficiency, where as another LPA may cite the deficiency regardless of whether the deficiency was corrected on-the-spot.