Inspection Reports for
American Care Homes, Inc.
4144 North 36th Street, Phoenix, AZ 85018, AZ, 85018
Back to Facility Profile7 Reports
Inspection Report — May 22, 2025
Enforcement
Date: May 22, 2025
Visit Reason
Civil monetary penalty, action 00131638 (invoice INV-304106), assessed 22 May 2025.
Findings
A $500.00 penalty was assessed and paid in full on 23 November 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — May 7, 2025
Annual Inspection
Date: May 7, 2025
Visit Reason
On-site complaint investigation of complaint 129792 and compliance (annual) inspection at a Behavioral Health Residential Facility, conducted 7 May 2025.
Complaint Details
The following deficiencies were found during the on-site investigation of complaint 129792 and compliance inspection conducted on May 7, 2025.
Findings
This inspection found six deficiencies related to personnel record maintenance, incomplete medication orders, resident access to unsafe materials, medication self-administration compliance, physical hazards on premises, and lack of privacy in resident bedrooms.
Deficiencies (6)
R9-10-706 — The administrator failed to ensure personnel records were maintained throughout an individual’s period of providing services for three of five personnel sampled, resulting in missing required documentation.
R9-10-712 — The administrator failed to ensure a resident's medical record contained medication orders for all medications administered, including missing orders for Olanzapine 10 mg and Clonidine HCL 600 mg.
R9-10-716 — The administrator failed to ensure a resident did not have access to materials that presented a threat to their health or safety, as the resident brought and used illicit substances while admitted.
R9-10-718 — The administrator failed to ensure assistance in the self-administration of medication was in compliance with a medication order, as a discontinued medication was documented without an updated order.
R9-10-721 — The administrator failed to ensure equipment was free from conditions that could cause physical injury, evidenced by a broken hallway bathroom window with jagged glass.
R9-10-722 — The administrator failed to ensure a resident’s bedroom had window or door covers that provide privacy, as a bedroom door window lacked adequate covering due to removal by residents.
Report Facts
Deficiencies cited: 6
Inspection Report — Feb 3, 2025
Complaint Investigation
Date: Feb 3, 2025
Visit Reason
On-site complaint investigation of complaint AZ00222239 at a Behavioral Health Residential Facility, conducted 3 February 2025.
Complaint Details
An on-site investigation of complaint AZ00222239 was conducted on February 3, 2025 and the following deficiency was cited.
Findings
The inspection found one deficiency related to the registered dietitian failing to ensure meals and snacks were served according to posted menus.
Deficiencies (1)
The registered dietitian failed to ensure that meals and snacks were served according to posted menus. The Compliance Officer observed discrepancies including missing soup, lemon meringue pie, breadsticks, and sandwiches listed on the menu.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 15, 2024
Annual Inspection
Date: Aug 15, 2024
Visit Reason
On-site complaint investigation of complaint AZ00209516 combined with an annual compliance inspection at a Behavioral Health Residential Facility, conducted 15 August 2024.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00209516 conducted on August 15, 2024.
Findings
This inspection found sixteen deficiencies related to licensing, staff training, personnel records, resident documentation, safety hazards, and infection control. The facility failed to maintain compliance with licensing requirements and staff training protocols, posing risks to resident health and safety.
Deficiencies (16)
A.R.S. § 36-407.E — The administrator failed to maintain the facility occupancy and operations within the scope of the licensed behavioral health residential facility subclass, including unauthorized use of a storage room as a bedroom.
The facility failed to develop and administer initial and continued competency training programs in fall prevention and fall recovery for staff, risking resident safety during falls.
The administrator failed to maintain personnel records documenting individual qualifications, including skills and knowledge applicable to job duties, for one of six personnel sampled.
The administrator failed to maintain documentation of education and experience applicable to job duties in personnel records for one of six personnel sampled.
The administrator failed to maintain current valid license or certification documentation in personnel records; an expired registered dietician license was on file without renewal documentation.
The administrator failed to maintain documentation of personnel compliance with A.R.S. §§ 36-411 and related statutes, including lack of good faith efforts to contact previous employers for one personnel record.
The administrator failed to maintain documentation of evidence of freedom from infectious tuberculosis in personnel records, posing a TB exposure risk to residents.
R9-10-113 — The administrator failed to maintain documentation of evidence of freedom from infectious tuberculosis in a resident's medical record, risking resident health and safety.
The administrator failed to ensure a resident's medical record contained documented general and informed consent for treatment, risking resident rights and safety.
The facility failed to ensure personnel completed required training before assisting residents with self-administration of medication, risking resident health and safety.
The administrator failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal, risking residents' ability to verify nutritional needs and dietary restrictions.
The administrator failed to maintain documentation of a current fire inspection; the fire department operating permit had expired and no current inspection documentation was available.
The administrator failed to ensure the premises were free from conditions that could cause physical injury; an uncovered electrical outlet was observed behind a resident's bed.
The administrator failed to maintain hot water temperatures within the required range of 95°F to 120°F; water temperature was observed at 127.9°F in the kitchen.
The administrator failed to ensure poisonous or toxic materials were stored in labeled containers in a locked area separate from food and medications; chemicals and food were stored together in a closet accessible to residents.
R9-10-113 — The facility failed to provide annual training and education on recognizing signs and symptoms of tuberculosis to staff, posing a TB exposure risk to staff and residents.
Report Facts
Deficiencies cited: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Administrator | Acknowledged multiple documentation and compliance failures in interviews. |
| Staff #1 | Personnel record lacking fall prevention training documentation. | |
| Staff #2 | Personnel record lacking fall prevention training and TB screening documentation. | |
| Staff #3 | Personnel record lacking fall prevention training and TB screening documentation. | |
| Staff #4 | Personnel record with expired license. | |
| Staff #6 | Personnel record lacking fall prevention training and TB screening documentation. |
Inspection Report — Mar 11, 2024
Complaint Investigation
Date: Mar 11, 2024
Visit Reason
On-site complaint investigation of complaint AZ00201766 at a Behavioral Health Residential Facility, conducted 11 March 2024.
Complaint Details
An on-site investigation of complaint AZ00201766 was conducted on March 11, 2024 and the following deficiency was cited.
Findings
The inspection found one deficiency where the administrator failed to ensure at least one personnel member was present and awake at the facility when a resident was on the premises.
Deficiencies (1)
An administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises, posing a risk to resident health and safety.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 13, 2023
Annual Inspection
Date: Jul 13, 2023
Visit Reason
On-site annual compliance inspection of a Behavioral Health Residential Facility conducted on July 13, 2023.
Findings
Four deficiencies were found related to personnel records, staffing presence, resident assessments, and tuberculosis screening. The inspection identified failures in maintaining clinical oversight documentation, ensuring awake staff presence, completing timely medical assessments, and obtaining tuberculosis clearance.
Deficiencies (4)
R9-10-115 — The administrator failed to ensure personnel records for behavioral health technicians included required documentation of clinical oversight, posing a risk to resident safety.
Staffing presence — The administrator failed to ensure at least one personnel member was awake at the facility when a resident was present, risking resident health and safety.
The administrator failed to ensure a medical practitioner or registered nurse performed a medical history and physical examination or nursing assessment within the required timeframe for one resident, risking inadequate treatment planning.
R9-10-113 — The administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven days after admission, posing a TB exposure risk.
Report Facts
Deficiencies cited: 4
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