12 Reports
Inspection Report — May 7, 2026
Enforcement
Date: May 7, 2026
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at the assisted living facility Avamere at Englewood Heights on May 7, 2026, resulting in the imposition of a civil fine.
Complaint Details
The visit was a complaint investigation conducted on May 7, 2026. The complaint was substantiated as the licensee failed to follow the negotiated service agreement, leading to a resident fall and injury.
Findings
The licensee failed to implement the Negotiated Service Agreement requiring two care staff to assist a resident in and out of bed. This failure contributed to a resident's fall causing injuries that required hospitalization, resulting in a $500 civil fine.
Deficiencies (1)
WAC 388-78A-2160 Implementation of negotiated service agreement. The licensee failed to implement the negotiated service agreement directing staff to assist a resident in and out of bed with two care staff. This failure contributed to a resident's fall resulting in hospitalization.
Report Facts
Civil fine amount: 500
Inspection Report — Nov 18, 2025
Re-Inspection
Date: Nov 18, 2025
Visit Reason
The inspection was a follow-up re-inspection triggered by a complaint and previous failed Fire Marshal inspection regarding fire safety compliance.
Complaint Details
The complaint investigation number 201203 found that the facility failed their first Fire Marshal re-inspection. The allegation was substantiated with citations written for noncompliance with fire safety requirements.
Findings
The facility failed the first Fire Marshal re-inspection due to noncompliance with fire safety regulations. Deficiencies related to the building's approval by the Washington state fire marshal were identified and citations were written.
Deficiencies (1)
WAC 388-78A-2040 Other requirements. The assisted living facility must have its building approved by the Washington state fire marshal to be licensed. The facility failed to maintain compliance as evidenced by failed initial and re-inspections placing residents, staff, and visitors at risk of harm from fire.
Report Facts
Total residents: 76
Resident sample size: 76
Inspection Report — Oct 30, 2025
Life Safety
Date: Oct 30, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility on 10/30/2025.
Findings
Multiple fire safety violations were identified, including issues with fire drill documentation, electrical hazards, power taps, door maintenance, duct protection, sprinkler system testing, and fire extinguishing system service. Several violations were corrected on site, but some remain open, resulting in a disapproved status.
Deficiencies (10)
IFC 404.2 (2021) - Fire safety, evacuation and lockdown plan contents were not fully compliant. Fire drill documentation showed drill start times noted only between shift transitions and all-staff meetings. Staff participation in drills must occur within their designated shifts.
IFC 603.2 (2021) - Electrical hazards included an electrical outlet without a faceplate and a broken outlet in Room 304 exposing inner electrical fixture, and an open junction box in the Break Room.
IFC 603.5 (2021) - Use of relocatable power taps and current taps was noncompliant. A multi-plug adapter without over current protection and extension cords in Room 309 were observed, including an extension cord taped to the riser hot/low point on the building exterior.
IFC 404.5 (2021) - Repair of penetrations was required. A penetration was found in the closet of the Executive Director's Office.
IFC 705.2 (2021) - Opening protectives in fire-resistance-rated assemblies were not maintained. The 3rd floor Mechanical Room door frame was broken and the door was unable to fully open. Several fire doors were propped open by wedges or unapproved magnetic locks, including rooms 317, 214, 122, 124, Dining Room, and two Copy Room hallway doors.
IFC 706.1 (2018) - Duct and air transfer openings were not properly maintained. The facility failed to provide documentation showing deficiencies noted on the fire and smoke damper service reports from 02/19/2023 were repaired and retested for compliance.
IFC 903.5 (2021) - Sprinkler systems were not properly tested and maintained. The facility failed to provide documentation of the annual forward flow test completed within the last twelve months and had loaded sprinkler heads on the exterior patio.
IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems were not properly serviced. The facility was unable to provide documentation for commercial hood system service reports from 10/09/2024 and 04/10/2025. Both reports noted deficiencies and suppression cylinders were not hydro tested within six years.
IFC 907.7 (2021) - Fire alarm system acceptance tests were incomplete. The facility was unable to provide acceptance testing documentation for the newly installed fire alarm control panel.
IFC 1031.10.2 (2021) - Battery-powered emergency lighting was not properly tested. The facility failed to provide documentation of the annual 90-minute emergency exit lighting test within the past twelve months.
Inspection Report — Oct 9, 2025
Complaint Investigation
Date: Oct 9, 2025
Visit Reason
The inspection was conducted in response to a complaint of smoking within a resident room at Avamere at Englewood Heights.
Complaint Details
Complaint #197540 alleged smoking inside a resident room. The resident reported smoking was occurring, but investigation found no evidence of smoking materials. The allegation was unsubstantiated and no violations were cited.
Findings
The inspection found no signs of smoking materials present and no fire or injuries occurred. The facility has a signed smoking policy and will continue efforts to maintain compliance. The inspection was approved with no violations observed.
Inspection Report — Jun 13, 2025
Follow-Up
Date: Jun 13, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Complaint Details
The complaint investigation (Compliance Determination #56316) involved allegations that staff performed CPR on a resident with a Do Not Attempt Resuscitation order and that the facility did not clearly communicate potential cost increases in the resident's contract. The investigation confirmed the CPR incident as a failed practice and found no failed practice regarding contract clarity.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to policies and procedures for medical emergencies were corrected.
Deficiencies (1)
WAC 388-78A-2600 (2)(f) Policies and Procedures. The facility failed to ensure staff followed policies regarding life-sustaining treatments, resulting in CPR performed on a resident with a Do Not Attempt Resuscitation order. This deficiency was previously cited and corrected after the follow-up inspection.
Report Facts
Total residents: 66
Resident sample size: 9
Document — May 22, 2025
Date: May 22, 2025
Visit Reason
This document communicates the results of an Informal Dispute Resolution process addressing disputes related to a prior Statement of Deficiencies report dated April 10, 2025.
Findings
The IDR process reviewed materials and statements from the facility and regional staff, resulting in no change to WAC 388-78A-2600 and deletion of WAC 388-78A-2980 from the deficiencies.
Notice — May 15, 2025
Date: May 15, 2025
Visit Reason
The document confirms the scheduling of a virtual Informal Dispute Resolution meeting requested by the facility to dispute specific citations from a prior Statement of Deficiencies dated April 10, 2025.
Findings
The letter does not contain inspection findings but outlines the process and participants for the upcoming IDR meeting regarding disputed citations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abiel Paz | Administrator | Named as a participant representing the facility in the IDR process. |
| Melissa Reynolds | Regional Nurse | Named as a participant representing the facility in the IDR process. |
| Mirella Gould | Director of Health Services | Named as a participant representing the facility in the IDR process. |
Inspection Report — Mar 17, 2025
Complaint Investigation
Date: Mar 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations that facility staff performed CPR on a resident with a Do Not Attempt Resuscitation (DNAR) order and concerns about the facility's clarity regarding contract cost increases.
Complaint Details
Complaint number 170331 alleged improper CPR on a DNAR resident and unclear contract cost notices. The CPR allegation was substantiated with a citation issued. The contract cost allegation was not substantiated.
Findings
The investigation confirmed that staff performed CPR on a DNAR resident due to conflicting instructions from the resident's spouse and 911 dispatch, constituting a failed practice and citation. The facility did not fail regarding contract cost notice. Additional consultation deficiencies related to pet immunizations and staff training were corrected on-site.
Deficiencies (1)
WAC 388-78A-2600 (2)(f) Policies and procedures. The facility failed to ensure staff followed policies regarding life-sustaining treatments, resulting in CPR performed on a resident with a Do Not Attempt Resuscitation order.
Report Facts
Total residents: 66
Resident sample size: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Health Services Director, Registered Nurse (RN) | Named in the finding related to performing CPR on the DNAR resident and communicating with family. |
Inspection Report — Nov 3, 2023
Complaint Investigation
Date: Nov 3, 2023
Visit Reason
The inspection was conducted as a result of multiple complaints alleging failure to respond timely to resident calls for assistance, improper medication administration, missing resident belongings, and failure to notify Construction Review Services of facility modifications.
Complaint Details
The complaint investigation involved multiple allegations including delayed staff response to resident calls, medication administration issues, missing resident belongings, and failure to notify construction modifications. The investigation substantiated the allegations of delayed response to calls and failure to notify construction review, resulting in citations. Other allegations were found unsubstantiated or corrected.
Findings
The investigation found failed provider practices related to untimely response to resident calls for assistance and failure to notify the department of planned and implemented physical modifications to the facility. Other allegations such as improper medication administration, missing belongings, and billing errors were found to have no failed facility practice. The facility was cited for these deficiencies.
Deficiencies (2)
WAC 388-78A-2600 1A and 2F Policies - The facility failed to implement their resident emergency call system policy to ensure staff responded timely to calls for assistance, resulting in residents waiting over 30 minutes for help.
WAC 388-78A-2850 - The facility failed to notify Construction Review Services of planned and implemented modifications to the assisted living facility's physical structure, including a mobile kitchen.
Report Facts
Total residents: 58
Resident sample size: 58
Closed records sample size: 1
Inspection Report — Aug 17, 2023
Life Safety
Date: Aug 17, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — Apr 25, 2023
Complaint Investigation
Date: Apr 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that the facility did not properly manage a resident's transfer process, denied the resident's return without seeing them, excluded the responsible party from meetings, and charged for care not received.
Complaint Details
The complaint investigation (Complaint #78363) alleged failure to explain transfer process, denial of resident return, exclusion of responsible party, and improper billing. The investigation substantiated these allegations and cited the facility for multiple deficiencies including licensing, service agreements, staff training, TB testing, food sanitation, and resident rights violations.
Findings
The investigation found that the facility failed to explain the transfer process, denied the resident's return, excluded the responsible party from meetings, and charged for services not provided. The facility was cited for failing to maintain a current license and other deficiencies, resulting in a failed provider practice with citations written.
Deficiencies (6)
WAC 388-78A-2030 Assisted living facility license required. The facility failed to maintain and post a current license for all 50 residents, resulting in care from an unlicensed facility.
WAC 388-78A-2150 Signing negotiated service agreement. The facility failed to ensure that the negotiated service agreement was signed and dated annually by 3 of 7 residents, risking lack of full disclosure of care and services.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure TB screening within three days of hire for 4 of 4 staff, placing residents at risk of communicable disease exposure.
WAC 388-78A-2450 Staff. The facility failed to provide orientation and appropriate training for expected duties to 3 of 4 staff, placing 50 residents at risk of care by untrained staff.
WAC 388-78A-2305 Food sanitation. The facility failed to ensure the dishwasher reached the required hot water sanitation temperature of 180 degrees, placing residents and others at risk of foodborne illness.
WAC 388-78A-2660 Resident rights. The facility failed to notify the resident and responsible party when the resident was transferred to a higher care level but continued to charge for care at the lower level.
Report Facts
Total residents: 50
Resident sample size: 7
Staff without TB screening: 4
Residents without signed NSA: 3
Days license expired: 203
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Named in findings related to lack of license and process failures |
| Staff G | Registered Nurse (RN) and Director of Health Services | Named in findings related to updating resident's negotiated service agreement |
| Staff H | Resident Care Coordinator | Named in findings related to negotiated service agreements |
| Staff J | Former Business Office Manager | Named in findings related to staff orientation and TB screening audits |
| Staff I | Diet Services Manager | Named in findings related to dishwasher temperature and sanitation process |
| Staff K | Dishwasher Operator | Named in findings related to dishwasher temperature and sanitation process |
Inspection Report — Mar 14, 2023
Life Safety
Date: Mar 14, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on March 14, 2023.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
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