8 Reports
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility based on complaint number 163920 regarding resident care and notification issues.
Complaint Details
Complaint number 163920 included allegations that a resident was unkept, had a wound upon discharge to hospital, and that the case manager was not informed of discharge. The investigation substantiated the failure to notify the case manager but found insufficient information to support the other allegations.
Findings
The investigation found that the facility failed to notify the resident's case manager upon discharge to the hospital, constituting a failed practice. Other allegations regarding resident wound status and condition were not supported by sufficient information. The facility corrected the identified issue after consultation.
Deficiencies (1)
WAC 388-78A-2640 - The assisted living facility failed to notify the resident’s case manager when the resident was discharged to the hospital as required.
Report Facts
Resident sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation |
Inspection Report — Apr 9, 2025
Follow-Up
Date: Apr 9, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to compliance determinations 57672 and 54639.
Complaint Details
The complaint investigation concerned a discharged resident who had been charged fees not owed. The investigation found that the facility failed to issue a refund owed to the resident's account after discharge and transfer to another facility. The failure was confirmed by interviews and record review, and a citation was written.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Deficiencies (1)
RCW 70.129.150 Disclosure of fees and notice requirements -- Deposits. The facility failed to provide a refund to a discharged resident within the required timeframe, causing undue stress to the resident and family. The refund was acknowledged but not issued as of the investigation date.
Report Facts
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Conducted the on-site verification and complaint investigation |
| Staff A | Lead Director of Resident Services | Acknowledged the refund was due but not sent |
Inspection Report — Jan 7, 2025
Annual Inspection
Date: Jan 7, 2025
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 01/07/2025 to determine compliance status.
Findings
The inspection found no deficiencies in the facility.
Inspection Report — Jun 11, 2024
Complaint Investigation
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation due to the facility failing the 3rd Fire Safety Inspection.
Complaint Details
The complaint investigation was triggered by the facility's failure of the 3rd Fire Safety Inspection. The investigation included interviews with the Administrator and Environmental Services Director, who confirmed awareness of outstanding corrections. The complaint number referenced is 132649.
Findings
The investigation found that the facility failed to meet all requirements for the third fire safety inspection, placing all 110 residents at risk of harm. The Administrator and Environmental Services Director acknowledged the outstanding corrections needed.
Deficiencies (1)
WAC 388-78A-2040 Other requirements. The assisted living facility failed a 3rd Fire and Life Safety Inspection from the Fire Marshall Inspectors office, placing all 110 residents at risk of harm.
Report Facts
Total residents: 110
Inspection Report — Mar 6, 2024
Re-Inspection
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a re-inspection to verify correction of previously cited deficiencies at the residential care facility.
Findings
The facility was disapproved due to multiple unresolved fire safety violations including lack of required documentation, failure to conduct required inspections and maintenance, and physical deficiencies such as unapproved equipment and unsecured compressed gas cylinders. Numerous fire safety system components were found non-compliant and documentation for required testing and servicing was missing.
Deficiencies (17)
IFC 604.10.1 2018 Only listed and labeled portable, electric space heaters shall be used. Unapproved portable space heaters were found in the activities office.
IFC 607.3.3 2018 Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. Unable to provide reports showing that two semi-annual kitchen hood cleanings were performed in the past 12 months.
IFC 701.6 2018 WAC 51-54A The owner shall maintain an inventory of all required fire-resistance-rated construction and conduct annual inspections. Facility failed to produce documentation of annual inspection and inventory of fire-resistance-rated construction and had multiple unprotected penetrations without plans identifying fire-resistance rating.
IFC 705.2 2018 Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained per NFPA 80 and NFPA 105. Hardware on fire door to main boiler/electrical room was modified with plastic parts, which is not permitted.
IFC 903.5 2009, 2012, 2015, 2018 Sprinkler systems shall be tested and maintained per Section 901. Facility was unable to provide fire sprinkler system documentation for quarterly inspections, annual confidence test, 3-year full flow trip test, 5-year inspection/test, and annual backflow control valve test. Loaded sprinkler head found in dish washing room and ordinary-rated sprinkler head found in walk-in cooler requiring replacement.
IFC 904.12.5.2 2018 Automatic fire-extinguishing systems shall be serviced at least semi-annually. Unable to provide documentation showing two semi-annual kitchen hood suppression system servicings in past 12 months. Kitchen hood found yellow-tagged with tag date January 2022 and no documentation of corrections.
IFC 904.5.2 2009, 2012, 2015, 2018 Fixed temperature-sensing elements shall be maintained. Unable to produce heat survey report showing correct fusible link rating for hood suppression system.
IFC 907.8 2018 Fire alarm and detection systems shall be maintained and tested per NFPA 72. Fire alarm system found in silence mode with unknown cause. Unable to produce documentation showing correction of deficiencies noted in January 26, 2024 annual fire alarm system confidence report.
IFC 915.6 2018 Carbon monoxide alarms and detection systems shall be maintained per NFPA 720. Unable to provide documentation showing monthly inspection of carbon monoxide alarms in past 12 months.
IFC 1013.6.3 2018 Exit signs shall be illuminated at all times with emergency power. Exit sign between rooms 534/535 failed to illuminate on battery backup when tested.
IFC 1031.10.1 2018 Emergency lighting equipment shall be tested monthly for at least 30 seconds. Unable to provide documentation showing monthly battery testing of emergency lighting and exit signs in past 12 months.
IFC 1031.10.2 2018 Battery-powered emergency lighting equipment shall be tested annually for 90 minutes. Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs in past 12 months.
IFC 5303.5.3 2018 Compressed gas containers, cylinders and tanks shall be secured to prevent falling. Found 17 unracked oxygen cylinders in 4th floor oxygen storage room requiring staff education.
IFC 5303.5.3 2018 Compressed gas containers, cylinders and tanks shall be secured to prevent falling. Found 17 unracked oxygen cylinders in 4th floor oxygen storage room requiring staff education.
NFPA 80 Fire Door Inspection and Testing Multiple fire doors throughout facility had painted frame labels, missing hardware screws, and door gaps exceeding allowed clearances. Facility unable to produce last annual fire door inspection report.
NFPA 80 Fire Door Inspection and Testing Multiple fire doors throughout facility had painted frame labels, missing hardware screws, and door gaps exceeding allowed clearances.
Fire Drills At least twelve planned and unannounced fire drills shall be held annually. Facility failed to conduct/document twelve planned and unannounced fire drills in past 12 months, missing night shift drill for 3rd quarter 2023 and day shift drill for 2nd quarter 2023.
Report Facts
Unracked oxygen cylinders: 17
Missing fire drills: 2
Inspection Report — Jan 2, 2024
Re-Inspection
Date: Jan 2, 2024
Visit Reason
The inspection was a re-inspection conducted by the Office of the State Fire Marshal to verify correction of previously cited deficiencies related to fire safety and code compliance at the residential care facility.
Findings
The facility was found to have multiple unresolved fire safety violations including lack of required documentation for fire sprinkler system inspections, fire door maintenance issues, unapproved portable heaters, failure to conduct required fire drills, and unsecured oxygen cylinders. The overall status is Disapproved, indicating violations remain uncorrected.
Deficiencies (14)
IFC 604.10.1 2018 - Only listed and labeled portable, electric space heaters shall be used. Unapproved portable space heaters were found in the activities office.
IFC 607.3.3 2018 - Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals. Unable to provide reports showing that two semi-annual kitchen hood cleanings were performed in the past 12 months.
IFC 701.6 2018 WAC 51-54A - The owner shall maintain an inventory of all required fire-resistance-rated construction and conduct annual inspections. Facility failed to provide annual inventory records and documentation of repairs; multiple unprotected penetrations found with no plans identifying fire-resistance rating.
IFC 705.2 2018 - Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained. Hardware on fire door to main boiler/electrical room modified with plastic parts on self-closing hinges.
IFC 903.5 2009, 2012, 2015, 2018 - Sprinkler systems shall be tested and maintained per Section 901. Facility unable to provide fire sprinkler system documentation including quarterly inspections, annual confidence test, 3-year full flow trip test, 5-year inspection, and backflow control valve test. Loaded sprinkler head found near air supply vent; ordinary-rated sprinkler head found in walk-in cooler requiring replacement with high temperature head.
IFC 904.12.5.2 2018 - Automatic fire-extinguishing systems shall be serviced at least semi-annually. Unable to provide reports showing two semi-annual kitchen hood suppression system servicings in past 12 months; kitchen hood yellow-tagged since January 2022 with no documentation of correction in past 24 months.
IFC 907.8 2018 - Fire alarm and detection systems shall be maintained and tested per NFPA 72. Fire alarm system found in silence mode; unable to provide documentation of annual servicing and smoke detector sensitivity testing in past 5 years.
IFC 915.6 2018 - Carbon monoxide alarms shall be maintained and inspected monthly. Unable to provide documentation showing monthly inspection of carbon monoxide alarms in past 12 months.
IFC 1013.6.3 2018 - Exit signs shall be illuminated at all times and connected to emergency power. Exit sign between rooms 534/535 failed to illuminate on battery backup when tested.
IFC 1031.10.1 2018 - Emergency lighting equipment shall be tested monthly for at least 30 seconds. Unable to provide documentation showing monthly battery testing of emergency lighting and exit signs in past 12 months.
IFC 1031.10.2 2018 - Battery-powered emergency lighting equipment shall be tested annually for 90 minutes. Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs; facility must conduct test to be in compliance at 30-day re-inspection.
IFC 5303.5.3 2018 - Compressed gas containers shall be secured to prevent falling. Found 17 unracked oxygen cylinders in 4th floor oxygen storage room; staff education required.
NFPA 80 Fire Door Inspection and Testing - Fire doors shall be inspected and maintained annually. Multiple fire doors found with painted frame labels, missing hardware screws, and door gaps exceeding allowed clearances.
Fire Drills - At least twelve planned and unannounced fire drills shall be held annually. Facility failed to conduct/document twelve fire drills in past 12 months including night shift drill for 3rd quarter 2023 and day shift drill for 2nd quarter 2023; must conduct fire drills for all shifts in January 2024 to be compliant.
Report Facts
Unracked oxygen cylinders: 17
Fire drills required annually: 12
Fire drills missing: 2
Inspection Report — Nov 9, 2023
Complaint Investigation
Date: Nov 9, 2023
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility due to allegations that the facility discarded belongings of a deceased resident.
Complaint Details
The complaint investigation involved multiple complaint numbers (92935, 95912, 98032, 99625, 99706) regarding deceased resident belongings discarded by the facility. The investigation included interviews with the resident representative and administrator, observations, and record reviews. The facility acknowledged the issue and implemented a new policy and restitution.
Findings
The investigation found that facility staff removed personal belongings from a discharged resident's apartment before the resident representative completed sorting them. The facility added a new policy for discharged residents' belongings and made monetary restitution to the resident representative. A failed provider practice was identified and citations were written.
Deficiencies (1)
WAC 388-78A-2600(2)(a) Policy and Procedures. The assisted living facility must develop, implement and train staff on policies related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of any resident. The facility failed to follow proper procedures regarding discharged resident belongings.
Report Facts
Resident sample size: 2
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Investigator who conducted the complaint investigation and provided consultation |
| Manfay Chan | Field Manager | Signed the letter regarding the complaint investigation |
Inspection Report — Apr 25, 2023
Life Safety
Date: Apr 25, 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 at this inspection.
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