6 Reports
Inspection Report — Aug 25, 2025
Life Safety
Date: Aug 25, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
The inspection identified several deficiencies related to fire resistance, fire sprinkler system documentation, emergency power, and emergency lighting. Most deficiencies were corrected on site, while some remain open due to lack of documentation or non-operational equipment. The overall approval status is Approved.
Deficiencies (10)
IFC 701.6 2021 - The owner must maintain an inventory of all required fire-resistance-rated construction and conduct annual inspections of all fire walls and rated ceilings/corridor walls. The facility did not provide last annual fire wall inspection records or indicate if the yearly inspection passed or failed.
Repair of penetrations - Various unsealed barrier penetrations were found throughout the facility's rated corridor and corridor walls due to piping, conduit, cables, and other penetrants. Firestopping is required and use of fire foam is prohibited.
IFC 705.2 2021 - Opening protectives in fire-resistance-rated assemblies must be inspected and maintained per NFPA standards. Fire doors and smoke/draft control doors must not be blocked or modified. This deficiency was corrected.
IFC 903.5 2021 - Sprinkler systems must be tested and maintained per Section 901. The fire sprinkler system was yellow-tagged with no corrective service reports; documentation for corrections and annual confidence test was missing.
IFC 904.13.5.2 2021 - Automatic fire-extinguishing systems must be serviced at least every six months and certificates forwarded to the fire code official. This deficiency was corrected.
IFC 907.8 2021 - Maintenance and testing schedules for fire alarm and detection systems must be maintained per NFPA 72. Records of inspection and testing were maintained and this deficiency was corrected.
IFC 915.6 2021 WAC - Carbon monoxide alarms and detection systems must be maintained and replaced if inoperable or end-of-life. This deficiency was corrected.
IFC 1013.6.3 2021 - Exit signs must be illuminated for at least 90 minutes during power loss by emergency power systems. Multiple exit signs failed to connect to backup power; the generator is no longer operational.
IFC 1032.10.1 2021 - Emergency lighting equipment must be tested monthly for at least 30 seconds. Documentation of monthly battery testing for emergency lighting and exit signs was not provided for the last 12 months.
IFC 1031.10.2 2021 - Battery-powered emergency lighting equipment must be tested annually for at least 90 minutes. This deficiency was corrected.
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
The Department of Social and Health Services conducted a complaint investigation of the Assisted Living Facility on 03/06/2025 due to complaints numbered 163668, 164456, and 165094.
Complaint Details
The complaint investigation included complaint numbers 163668, 164456, and 165094. The deficiency related to medication services was substantiated and corrected on-site.
Findings
The investigation found that the facility did not meet Assisted Living Facility requirements related to medication services. A deficiency was identified regarding the lack of a process to verify delivery or pickup of medications for self-medicating residents. This deficiency was corrected on-site.
Deficiencies (1)
WAC 388-78A-2210 Medication services. The facility lacked a process for verifying that medications had been delivered or picked up by self-medicating residents. This deficiency was corrected on-site.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Named as department staff who did the inspection and provided consultation. |
Inspection Report — Feb 20, 2025
Follow-Up
Date: Feb 20, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication safety assessments.
Complaint Details
The complaint investigation (Complaint #156564) alleged residents were self-medicating without safety assessments. The investigation found failed provider practice with citations written for lack of medication safety assessments for 6 sampled residents.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited deficiencies were corrected, meeting Assisted Living Facility licensing requirements.
Deficiencies (1)
WAC 388-78A-2090-2-a The facility failed to obtain sufficient information to provide a safe self-medication system for 6 of 6 sampled residents, placing them at risk when taking medication without a safety assessment of understanding prescribed medications.
Report Facts
Resident sample size: 6
Residents independently administering medications: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Stated unawareness of medication safety assessment policy |
| Staff C | Medication Technician | Reported 21 residents independently administering medications and unawareness of self-medication policy |
| Staff B | Resident Care Coordinator | Stated unawareness of medication safety assessments |
| Staff D | Medication Technician | Aware of residents independently administering medications but unaware of self-medication policy |
Inspection Report — Dec 12, 2023
Follow-Up
Date: Dec 12, 2023
Visit Reason
The Department completed a follow-up inspection of the Charlton Place Assisted Living Facility on 12/12/2023 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to pet examinations and immunizations, and maintenance and housekeeping were corrected.
Deficiencies (2)
WAC 388-78A-2620 Pets. The facility failed to ensure pets living in the assisted living facility had regular examinations and immunizations by a licensed veterinarian, placing residents at risk of diseases transmissible by animals.
WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to maintain safety and quality of common resident areas, including gouged walls, dim lighting, dirty air intake covers, cracked and uneven flooring, and damaged baseboard heating units, placing all 76 residents at risk for falls and decreased quality of life.
Report Facts
Residents in facility: 76
Sampled residents: 3
Inspection Report — Apr 18, 2023
Life Safety
Date: Apr 18, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility on 04/18/2023.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — Sep 8, 2022
Complaint Investigation
Date: Sep 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that a resident did not have running water in his room and concerns about the environment conditions and overall wellbeing of the resident.
Complaint Details
The complaint investigation (Complaint #42413) was based on allegations that a resident lacked running water in his room and the room's environment was unsafe and unsanitary. The investigation substantiated the complaint with findings of unsanitary conditions and failure to maintain safe living quarters. The facility was cited for deficiencies.
Findings
The investigation found that the facility failed to maintain and provide safe and sanitary living quarters for the resident. A deficiency was cited related to maintenance and housekeeping, specifically unsafe and unsanitary conditions in the resident's room.
Deficiencies (1)
WAC 388-78A-3090 Maintenance and housekeeping. The assisted living facility failed to provide a safe, sanitary, and well-maintained environment for residents as evidenced by unsanitary conditions in a resident's room including soiled linens, strong urine odor, stained mattress, and cluttered bedside table.
Report Facts
Total residents: 83
Resident sample size: 5
Closed records sample size: 0
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