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correction orders using federal software. Please disregard the heading of the fourth column that states, "Provider's Plan of Correction." A plan of correction is not required. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 HHH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 PRINTED: 11/19/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 32917 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3820 HOFFMAN ROAD THE WATERS OF WHITE BEAR LAKE WHITE BEAR LAKE, MN 55110 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 SL32917016-0 On October 14, 2024, through October 15, 2024, the Minnesota Department of Health conducted a survey at the above provider. At the time of the survey, there were 134 residents; 58 receiving services under the Assisted Living with Dementia Care license. As a result of the survey, the licensee was found to be in compliance with the assisted living statutes 144G.08 through 144G.95. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OE6T11 If continuation sheet 1 of 1 Food Pools & Lodging Services St Paul, MN 55164-0975 Type: Full Page 1 Food and Beverage Establishment Date: 10/14/24 Inspection Report Time: 10:11:48 Report: 8058241267 Location: Establishment Info: The Waters Of White Bear Lake ID #: 0038043 Risk: 3820 Hoffman Road Announced Inspection: No White Bear Lake, MN55110 Ramsey County, 62 License Categories: Operator: Phone #: 6513136440 Expires on: / / ID #: The violations listed in this report include any previously issued orders and deficiencies identified during this inspection. Compliance dates are shown for each item. No NEW orders were issued during this inspection. Surface and Equipment Sanitizers Quaternary Ammonia: = 200 PPM at --- Degrees Fahrenheit Location: DISPENSER Violation Issued: No Hot Water: = --- at 171 Degrees Fahrenheit Location: DISH MACHINE Violation Issued: No Food and Equipment Temperatures Process/Item: TOMATO Temperature: 38 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: CHICKEN SALAD Temperature: 37 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: EGG SALAD Temperature: 41 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: HAM Temperature: 37 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: TURKEY Temperature: 38 Degrees Fahrenheit - Location: PREP Violation Issued: No Type: Full Page 2 Food and Beverage Establishment Date: 10/14/24 Inspection Report Time: 10:11:48 Report: 8058241267 The Waters Of White Bear Lake Process/Item: BEEF ROAST Temperature: 41 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: CHICKEN Temperature: 38 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: PORK Temperature: 40 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: STRAWBERRY Temperature: 38 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Total Orders In This Report Priority 1 Priority 2 Priority 3 0 0 0 HRD INSPECTOR BRANDON MUELLER COMMERCIAL KITCHEN SPACE TWO REMOTE KITCHENS IN MEMORY CARE UNITS ARE NO LONGER USED FOR STORAGE AND ARE LIMITED TO USE ONLY DURING IMMEDIATE SERVICE DISCUSSED EMPLOYEE EXCLUSION, SICK TIME, PERSON TO PERSON ILLNESS POTENTIAL, SHELLED EGG USE, COOLING/COOKING OF WHOLE MUSCLE ROAST NOTE: Plans and specifications must be submitted for review and approval prior to new construction, remodeling or alterations. I acknowledge receipt of the Minnesota Department of Health inspection report number 8058241267 of 10/14/24. RYAN BECKER Certified Food Protection Manager: 87036 04/18/26 Certification Number: Expires: Inspection report reviewed with person in charge and emailed. Signed: Signed: RYAN BECKER Aaron Gertz PIC Sanitarian 3 MDH Metro Office health.foodlodging@state.mn.us