3 Reports
Inspection Report — Nov 10, 2025
Follow-Up
Date: Nov 10, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire marshal re-inspection failures.
Complaint Details
The facility failed their fire marshal re-inspection, which was the basis for the complaint investigation (Complaint Number 194079). The investigation confirmed the failure to maintain compliance with fire safety requirements, resulting in citations. The follow-up inspection later found all deficiencies corrected.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited violations were corrected, meeting Assisted Living Facility licensing requirements.
Deficiencies (5)
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 with this requirement during initial and re-inspections.
WAC 388-78A-2040 The facility failed to provide documentation of the annual forward flow testing within the last twelve months.
WAC 388-78A-2040 The facility failed to provide documentation that the annual fire alarm system inspection, testing, and maintenance was completed within the past twelve months.
WAC 388-78A-2040 The facility failed to lock the fire alarm circuit breaker to prevent accidental disconnection.
WAC 388-78A-2040 The facility failed to provide documentation of the monthly 30-minute full load testing for both emergency generators.
Report Facts
Total residents: 55
Resident sample size: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Cantu | Community Complaint Investigator | Conducted the complaint investigation and on-site verification |
Inspection Report — Nov 10, 2025
Life Safety
Date: Nov 10, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection found multiple violations related to fire protection systems, testing, and maintenance. Several violations were noted as corrected on site, while some citations remain uncorrected. The overall approval status is Approved.
Deficiencies (3)
IFC 903.5 (2021) Sprinkler systems shall be tested and maintained in accordance with Section 901. The facility was unable to provide documentation of the annual forward flow testing within the last twelve months.
IFC 907.8 (2021) The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be maintained. The facility failed to provide documentation that the annual fire alarm system inspection, testing, and maintenance was completed within the past twelve months. The facility failed to provide documentation that the semi-annual fire alarm system inspection, testing, and maintenance was completed within the past twelve months. On the 1st floor at panel 1-D, the fire alarm circuit breaker was not locked to prevent accidental disconnection.
IFC 1203.4 (2021) Emergency and standby power systems shall be maintained in accordance with NFPA 110 and NFPA 111. The facility was unable to provide documentation of the weekly inspections and monthly 30-minute full load testing for both emergency generators.
Inspection Report — Sep 8, 2025
Life Safety
Date: Sep 8, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire protection and life safety inspection at the residential care facility.
Findings
Multiple fire and life safety violations were identified, including unsecured electrical panels, missing documentation for fire system inspections and maintenance, and issues with delayed egress locking systems. Several violations were corrected on site, but some remain uncorrected, resulting in a disapproved status.
Deficiencies (17)
IFC 603.2 2021 - Unsafe electrical hazards were found including a fridge plugged into a power strip in the Dining Room Office. This was corrected on site.
IFC 603.4 2021 - Multiple electrical panels on various floors were unsecured or broken, including panels in laundry rooms, Coke-a-Cola Room, RCC, Med Room, Kitchen, and Room 324. All were corrected on site.
IFC 603.5.2 2021 - A power strip was plugged into a power strip in the Life Enrichment Office. This was corrected on site.
IFC 603.6 2021 - Extension cords were found in use in Room 202 and Room 215. Both violations were corrected on site.
IFC 701.6 2018 WAC 51-54A - Facility was unable to provide documentation of fire-resistance rated wall inspections within the past twelve months. This violation was corrected on site.
IFC 701.6 2021 - Penetrations behind doors and equipment on multiple floors were found and corrected on site, including in Room 202, Receptionist Office, FACP room, and Business Office.
IFC 705.2.3 2021 - Manual hooks not tied into fire alarm system were found in RCC Office and DNS Office. Corrected on site.
IFC 705.2.4 2021 - The main entrance door and Dining Room door in Memory Care unit failed to close and latch from fully open position. Corrected on site.
IFC 901.6 2021 - Facility was unable to provide documentation of annual forward flow testing for fire protection systems. This violation remains uncorrected.
IFC 903.5 2021 - Facility failed to provide documentation of annual forward flow testing and had a missing escutcheon cap in the Christmas Room. The missing cap was corrected; documentation remains uncorrected.
IFC 904.13.5.2 2021 - Facility failed to provide documentation of semi-annual hood suppression system service within past twelve months. Service was provided for July 2024 and violation was corrected on site.
IFC 907.8 2021 - Facility failed to provide documentation that annual and semi-annual fire alarm system inspections, testing, and maintenance were completed within the past twelve months. Violations remain uncorrected, including unlocked fire alarm circuit breaker.
IFC 1010.1 2021 - Curtains hanging on doors in Life Enrichment Office were not compliant with NFPA 701 flame resistant requirements. Corrected on site.
IFC 1010.1.10 2021 - Panic hardware frame was broken on east corridor exit door but door remained operational. Corrected on site.
IFC 1203.4 2021 - Facility failed to provide documentation of annual service and maintenance for emergency generators and fuel sample testing. Some documentation was corrected on site; weekly and monthly inspections remain uncorrected.
IFC 1010.2.13.1 2021 - Missing signs for delayed egress doors and emergency lighting on egress side of doors in Memory Care unit. Corrected on site.
IFC 1010.2.13.1 2021 - Delayed egress locking system doors exceeded minimum pressure to release on multiple doors in Dining Room, Kitchen, and Memory Care unit. Corrected on site.
Report Facts
Next inspection scheduled date: Oct 8, 2025
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