8 Reports
Inspection Report — Apr 9, 2026
Follow-Up
Date: Apr 9, 2026
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to resident elopement and policy noncompliance.
Complaint Details
Complaint number 213565 involved a resident eloping from a locked memory care unit. The investigation found the facility failed to follow policy for head counts after alarms. Citations were written and the complaint was substantiated.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited deficiencies were corrected. The facility meets Assisted Living Facility licensing requirements.
Deficiencies (1)
WAC 388-78A-2600 Policies and Procedures. The facility failed to follow its policy requiring staff to complete a head count after an alarm sounded for a resident elopement, resulting in a resident leaving the facility without staff knowledge and placing all memory care residents at risk.
Report Facts
Total residents: 54
Resident sample size: 3
Inspection Report — Mar 24, 2026
Life Safety
Date: Mar 24, 2026
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to verify compliance with fire protection and life safety codes.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Inspection Report — Jan 26, 2026
Complaint Investigation
Date: Jan 26, 2026
Visit Reason
The inspection was an unannounced on-site complaint investigation triggered by allegations of life safety code violations and physical environment risks related to three failed fire marshal visits.
Complaint Details
Complaint number 208787 alleged life safety code violations and physical environment risks due to three failed fire marshal visits. The investigation substantiated these allegations with citations issued for failure to comply with fire marshal requirements and fire sprinkler testing.
Findings
The facility failed to comply with state fire marshal requirements, specifically failing to maintain compliance with fire ordinances and failing to provide required 10-year dry pendant fire sprinkler head testing. This failure placed residents, visitors, and staff at risk of injury and harm in the event of a fire. Citations were written for these deficiencies.
Deficiencies (1)
WAC 388-78A-2040 Other requirements. The assisted living facility must have its building approved by the Washington state fire marshal in order to be licensed. The facility failed to maintain compliance with local and state fire ordinances, including failure to provide required 10-year dry pendant fire sprinkler head testing and forward flow testing.
Report Facts
Total residents: 54
Resident sample size: 54
Inspection Report — Jan 14, 2026
Life Safety
Date: Jan 14, 2026
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Highgate Senior Living Vancouver to assess compliance with fire protection and safety codes.
Findings
The facility was found to be noncompliant with multiple fire safety requirements, including failure to provide required inspection reports and maintenance documentation. The overall approval status was Disapproved.
Deficiencies (4)
IFC 903.5 2021 - Facility failed to provide the 10 year dry pendant fire sprinkler head testing and forward flow testing reports as required for sprinkler system maintenance.
IFC 904.13.5.2 2021 - Automatic fire-extinguishing systems must be serviced at least every six months and after activation. A certificate of inspection must be forwarded to the fire code official upon completion.
IFC 907.8 2021 - Maintenance and testing schedules for fire alarm and detection systems must be followed with records maintained. Facility failed to provide required inspection, testing, and maintenance reports.
IFC 703.2 - Opening protectives must be maintained in operative condition with no blocking or obstruction. Fire door assemblies shall not be modified. Expandable foam shall be removed on any through penetration requiring a fire rating.
Inspection Report — Nov 12, 2025
Life Safety
Date: Nov 12, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility on 11/12/2025.
Findings
The inspection found multiple deficiencies related to fire safety and maintenance, including failure to provide required inspection reports and inadequate maintenance of fire protection systems. The facility was disapproved due to these unresolved violations.
Deficiencies (12)
IFC 603.2 (2021) - Abatement of unsafe electrical hazards is required to prevent electrical shock or fire hazards.
IFC 603.4 (2021) - Working space and clearances around electrical equipment must comply with NFPA 70 requirements.
IFC 701.6 (2021) - Facility must conduct an annual inspection of fire resistance rated construction.
IFC 703.2 - Opening protectives must be maintained in operative condition per NFPA 80, including removal of expandable foam on penetrations requiring fire rating.
IFC 705.2 (2021) - Opening protectives in fire-resistance assemblies must be inspected and maintained; facility failed to provide required inspection reports.
IFC 903.5 (2021) - Sprinkler systems must be tested and maintained; facility failed to provide quarterly and flow testing reports and sprinkler head testing.
IFC 904.13.5.2 (2021) - Automatic fire-extinguishing systems must be serviced at least every six months; facility failed to conduct semi-annual testing and maintain records.
IFC 907.8 (2021) - Fire alarm and detection systems must be maintained with records; facility failed to provide semi-annual and annual fire alarm inspection reports including elevator shaft detector testing.
IFC 1010.1.3 (2021) - Door opening force must comply with specified limits; emergency exit by room 219 fails to release properly.
IFC 1031.10.2 (2021) - Battery-powered emergency lighting must be tested annually; facility failed multiple tests during site visit.
IFC 1203.4 (2021) - Emergency and standby power systems must be maintained to supply service within required time; generator clearance around it is insufficient.
IFC 1203.4 (2021) - Facility failed to conduct fire drills once per shift per quarter as required.
Report Facts
Next inspection scheduled: Dec 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Davis | Maint Manager | Named as Owner or Authorized Representative signing the report |
Inspection Report — Oct 23, 2024
Follow-Up
Date: Oct 23, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 10/23/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected as documented.
Deficiencies (2)
WAC 388-78A-2484 Tuberculosis Two Step Skin Testing. The facility failed to complete tuberculosis testing within three days of hire for 3 of 3 sampled staff, placing staff and residents at risk of communicable disease exposure.
WAC 388-78A-2390 Resident records. The facility failed to maintain an accurate resident characteristic roster documenting care needs and services for 14 of 24 residents, risking unmet care needs.
Report Facts
Sampled residents: 7
Current residents: 56
Residents with inaccurate records: 14
Total residents: 24
Staff sampled for TB testing: 3
Inspection Report — Oct 24, 2023
Re-Inspection
Date: Oct 24, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to verify that all violations noted during previous related inspections have been corrected.
Findings
All violations noted during previous related inspections have been corrected, resulting in an approved status for this inspection.
Inspection Report — Aug 31, 2023
Annual Inspection
Date: Aug 31, 2023
Visit Reason
The Office of the State Fire Marshal conducted an annual fire and life safety inspection of Highgate Senior Living Vancouver to identify violations and ensure compliance with fire safety regulations.
Findings
The inspection found multiple fire and life safety violations including improper use of power taps, lack of kitchen hood suppression system, failure to maintain fire-resistance-rated construction, missing annual and periodic fire system inspections and tests, and malfunctioning door closers. The facility was disapproved due to failure to meet compliance requirements.
Deficiencies (10)
IFC 0605.4.1 - Relocatable power taps shall be of the polarized or grounded type, equipped with overcurrent protection, and shall be listed in accordance with UL 1363. Non approved power tap found in nurse station.
IFC 605.4.2 - Relocatable power taps shall be directly connected to a permanently installed receptacle. Facility failed to plug power strip directly into outlet in nurse station.
IFC 605.6 - Open junction boxes and open-wiring splices shall be prohibited. Approved covers shall be provided for all switch and electrical outlet boxes. Open electrical wiring found in break room adjacent to kitchen.
IFC 609.2 2015 WAC 51-54A - A Type I hood shall be installed at or above all commercial cooking appliances and domestic cooking appliances used for commercial purposes that produce grease laden vapors. Facility failed to have kitchen cooking appliance inside hood suppression system; appliance is about 2 inches outside of hood on left and right side.
IFC 701.6 2018 WAC 51-54A - The owner shall maintain an inventory of all required fire-resistance-rated construction and visually inspect it annually. Facility failed to provide annual fire door inspection reports.
IFC 703.2.2 - Hold-open devices and automatic door closers shall be maintained and doors remain closed when devices are out of service. Laundry room door and resident room 207 door fail to self-close as required.
IFC 706.1 2018 - Dampers protecting ducts and air transfer openings shall be inspected and maintained in accordance with NFPA 80 and NFPA 105. Facility failed to provide 4 year fire damper testing.
IFC 903.5 2009, 2012, 2015, 2018 - Sprinkler systems shall be tested and maintained in accordance with Section 901. Facility fails to provide annual forward flow testing and quarterly fire sprinkler inspections.
IFC 907.8 - The maintenance and testing schedules and procedures for fire alarm and fire detection systems shall be in accordance with Sections 907.8.1 through 907.8.5 and NFPA 72. Facility failed to provide annual fire alarm inspection.
IFC 912.7 - All fire department connections shall be periodically inspected, tested and maintained in accordance with NFPA 25. Records of inspection, testing and maintenance shall be maintained. Facility failed to provide 5 year FDC hydro testing.
Report Facts
Next inspection scheduled: Sep 30, 2023
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