10 Reports
Inspection Report — Mar 27, 2026
Complaint Investigation
Date: Mar 27, 2026
Visit Reason
On-site complaint investigation of complaint 00161391 at an Assisted Living Home, conducted 27 March 2026.
Complaint Details
The following deficiencies were found during the on-site investigation of complaint 00161391 conducted on March 27, 2026.
Findings
This inspection found 15 deficiencies related to management, staff training, documentation, medication administration, and resident safety. Several deficiencies were repeat citations from prior inspections.
Deficiencies (15)
A.R.S. § 36-420.01.A — The governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery for two of four sampled staff, posing a risk if staff were not properly trained to assist residents who had fallen.
R9-10-803 — The governing authority failed to designate, in writing, a manager who had a certificate as an assisted living facility manager, resulting in no certified manager for 24 days.
R9-10-803 — The governing authority failed to designate, in writing, an acting manager with required qualifications when the manager was not present on the premises for more than 30 days, leaving the facility without an active and present manager.
R9-10-803 — The governing authority failed to ensure compliance with fingerprint clearance card requirements and good faith efforts to verify clearance for two of four sampled personnel, posing a risk if employees were a danger to residents.
R9-10-806 — The manager failed to ensure assistant caregivers interacted with residents under supervision of a manager or caregiver, leaving residents alone with uncertified individuals.
R9-10-806 — The manager failed to verify and document assistant caregivers' skills and knowledge before providing physical health services for two sampled assistant caregivers, risking inadequate resident care.
R9-10-806 — The manager failed to maintain documentation for at least 12 months of caregivers and assistant caregivers working each day, including hours worked, resulting in inaccurate staff presence records.
R9-10-806 — The manager failed to ensure that at least the manager or a caregiver was present when residents were present, leaving residents alone with untrained individuals.
R9-10-807 — The manager failed to ensure documented residency agreements existed for two sampled residents, risking residents being uninformed of residency terms.
R9-10-811 — The manager failed to ensure residents' medical records contained medication orders for administered medications, including seven medications for one resident and an unsigned order for another, risking resident harm.
R9-10-815 — The manager failed to ensure a means of exiting the facility for residents without keys or special knowledge was monitored or alerted staff, as an alert on a sliding glass door was turned off.
R9-10-817 — The manager failed to ensure medications were administered in compliance with medication orders for two sampled residents, including administration without proper orders and incomplete documentation.
R9-10-817 — The manager failed to ensure medication administration was documented in residents' medical records for four residents, risking inability to verify medication administration.
R9-10-817 — The manager failed to ensure medication was stored in a separate locked area, as an unlocked closet and an unlocked medication lock box were accessible to residents.
R9-10-818 — The manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal, risking inability to identify sources of food-borne illness.
Report Facts
Deficiencies cited: 15
Inspection Report — Mar 11, 2026
Complaint Investigation
Date: Mar 11, 2026
Visit Reason
On-site complaint investigation at an Assisted Living Home, conducted 11 March 2026.
Complaint Details
On March 11, 2026, an off-site review of the plan of correction (POC) was conducted. Although some of the POC requirements were not met, the POC was accepted for all citations due to the compliance inspection conducted May 9, 2025.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Aug 16, 2025
Enforcement
Date: Aug 16, 2025
Visit Reason
Civil monetary penalty, action 00133583 (invoice INV-286596), assessed with partial payment status as of 16 August 2025.
Findings
A $1,000.00 penalty was assessed and partially paid with $250.00 paid and $750.00 remaining as of 16 August 2025.
Report Facts
Penalty amount: 1000
Amount paid: 250
Amount remaining: 750
Inspection Report — May 9, 2025
Annual Inspection
Date: May 9, 2025
Visit Reason
On-site complaint investigation of complaint 00129767 combined with an annual compliance inspection at an Assisted Living Home, conducted 9 May 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00129767 conducted on May 09, 2025.
Findings
This inspection found sixteen deficiencies related to documentation, resident service plans, tuberculosis screening, medication storage, and emergency preparedness. The facility failed to maintain required standardized forms, residency agreements, service plans, and medication orders, among other issues.
Deficiencies (16)
A.R.S. § 36-420.04.C — The manager failed to maintain a standardized form for each resident that included all required information for emergency responders, missing documentation for three residents sampled.
R9-10-113 — The health care institution failed to establish, document, and implement tuberculosis infection control activities, including annually assessing the risk of exposure to infectious TB.
R9-10-803 — The manager failed to conspicuously post the location where the most recent Department inspection report and plan of correction could be viewed.
R9-10-804 — The manager failed to maintain the quality management report and supporting documentation for at least 12 months after submission to the governing authority.
R9-10-807 — The manager failed to ensure residents provided evidence of freedom from infectious tuberculosis as required, missing documentation for three residents sampled.
R9-10-807 — The manager failed to ensure a resident submitted documentation signed by a medical practitioner or registered nurse stating whether continuous medical or nursing services or restraints were required.
R9-10-807 — The manager failed to ensure a documented residency agreement was in place before or at the time of acceptance for one resident.
R9-10-808 — The manager failed to ensure a resident's written service plan included a description of medical or health problems, missing documentation of exit-seeking behavior for one resident.
R9-10-808 — The manager failed to ensure the written service plan included the signature and date from the resident or representative for one resident.
R9-10-811 — The manager failed to ensure residents' medical records contained medication orders from a medical practitioner for each administered medication for two residents.
R9-10-811 — The manager failed to ensure documentation of a resident's orientation to exits from the assisted living facility was in the medical record for one resident.
R9-10-811 — The manager failed to ensure a resident's medical record contained the signed residency agreement, missing the signature page for one resident.
R9-10-815 — The manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or a medical practitioner's statement that weighing was contraindicated.
R9-10-815 — The manager failed to ensure a means of exiting the facility provided access to an outside area at least 30 feet away and controlled or alerted employees of resident egress; the door alarm was not functioning.
R9-10-816 — The manager failed to ensure medication was stored in a separate locked area; an unlocked medication lockbox was observed in the refrigerator accessible to residents.
R9-10-818 — The manager failed to ensure the disaster plan was reviewed at least once every 12 months; no documentation of review was available.
Report Facts
Deficiencies cited: 16
Inspection Report — Jan 7, 2025
Enforcement
Date: Jan 7, 2025
Visit Reason
Civil monetary penalty, action 00109332 (invoice INV-256661), assessed starting 7 January 2025.
Findings
A $2,500.00 penalty was assessed and partially paid with $550.00 paid and $1,950.00 remaining as of the payment schedule dated 27 February 2025.
Report Facts
Penalty amount: 2500
Amount paid: 550
Amount remaining: 1950
Inspection Report — Nov 19, 2024
Complaint Investigation
Date: Nov 19, 2024
Visit Reason
On-site complaint investigation of complaint AZ00218383 at an Assisted Living Home, conducted 19 November 2024.
Complaint Details
An on-site investigation of complaint AZ00218383 was conducted on November 19, 2024, and seven deficiencies were cited.
Findings
The inspection found seven deficiencies related to supervision of staff, documentation, personnel records, resident acceptance documentation, medical records, exit alert mechanisms, and medication administration documentation.
Deficiencies (7)
The manager failed to ensure an assistant caregiver interacted with residents under supervision, as E3 worked alone providing direct services without qualifications or personnel records.
The manager failed to maintain documentation of caregivers and assistant caregivers working each day, including hours worked, for several months.
R9-10-115 — The manager failed to maintain personnel records including required information for two employees, E3 and E4, posing a risk of unverifiable qualifications.
The manager failed to ensure residents submitted documentation dated within 90 days before acceptance regarding need for continuous medical, nursing services, or restraints for three sampled residents.
The manager failed to establish and maintain a medical record for one resident, R3, who had just arrived and had no medical record available.
The manager failed to ensure exit alert mechanisms were working on doors, risking unawareness of resident egress from the facility.
The manager failed to ensure medication administration was documented in residents' medical records for three sampled residents receiving medication.
Report Facts
Deficiencies cited: 7
Inspection Report — May 22, 2024
Monitoring
Date: May 22, 2024
Visit Reason
On-site abbreviated initial follow-up inspection (Initial Monitoring) at an Assisted Living Home conducted 22 May 2024.
Findings
No deficiencies were found during this inspection.
Inspection Report — Feb 15, 2024
Original Licensing
Date: Feb 15, 2024
Visit Reason
On-site initial licensing inspection of Garden Enclave Assisted Living Homes conducted 15 February 2024.
Findings
No deficiencies were found during this initial inspection.
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