On Dec. 26, 2012, a respiratory therapist from appellant O’Connor Hospital, in San Jose, provided a female patient with Amyotrophic Lateral Sclerosis (Lou Gherig’s Disease) her routine tracheostomy care. The female patient was a patient at the subacute unit at O’Connor Hospital, which had a separate license and was considered a skilled nursing facility. The patient, then age 60, was on a ventilator after a tracheostomy. During the routine tracheostomy care in December 2012, the respiratory therapist had the ventilator turned to standby mode, which would not provide any oxygen to the patient. However, when he concluded his care, he mistakenly forgot to turn the ventilator back on, leaving it in standby mode. Subsequently, 10 minutes later, a nurse came in and found the patient unresponsive. A Code Blue was called, and it was noted during the code that the ventilator was on standby. The patient was ultimately able to be resuscitated and then transferred to the Intensive Care Unit, but she was determined to be brain dead. As a result, she was taken off life support on Dec. 28, 2012, and she died a few minutes later. The patient’s family filed a civil claim against the hospital, and the matter ultimately settled. The California Department of Public Health investigated the case and issued an AA citation, which is a violation that the California Department of Public Health determined was a direct proximate cause of the death of a patient or resident of a long term care facility. As a result, O’Connor Hospital was fined $85,000. O’Connor Hospital subsequently filed an appeal in Santa Clara County Superior Court, disputing the California Department of Public Health’s finding. Counsel for O’Connor Hospital noted that the alleged violation was based on the California Department of Public Health’s finding that the hospital violated a federal regulation, 42 CFR § 483.25(h), for quality of care. The regulation required that a skilled nursing facility provide an environment that is free from accident hazards and required that patients receive adequate supervision and assistive devices. Counsel for O’Connor Hospital contended that the California Department of Public Health relied upon a publication from the Federal Government State Operations Manual to interpret the regulation and determined that the placement of the ventilator on standby mode was a violation of that regulation. However, counsel for O’Connor Hospital argued that the regulation did not apply to negligent care, as was the case in the subject patient’s death. Counsel also argued that the hospital should not be fined. The appellant’s respiratory therapy expert testified that the hospital’s respiratory therapist followed the procedure and simply forgot to turn the ventilator on. Counsel for the California Department of Public Health contended that the respiratory therapist did not follow the manual for the ventilator and that the Department of Public Health applied the appropriate regulation. Counsel argued that the state operations manual determines the applicable federal regulation and that the California Department of Public Health, as a regulatory agency, should be given deference on how to interpret regulations. The respondent’s respiratory therapist expert opined that the hospital’s respiratory therapist misused the ventilator and did not follow the manual’s user recommendations. Thus, the respondent’s geriatrics expert testified that the federal regulation in question did apply to the subject situation, where there was a violation of care. In response, counsel for O’Connor Hospital noted that nothing in the ventilator’s manual stated that standby mode should not be used., O’Connor Hospital claimed that the $85,000 fine issued by the California Department of Public Health was too large, as the range of fines was from $25,000 to $100,000. Thus, the hospital claimed that, if anything, the fine should be reduced to $25,000.