6 Reports
Inspection Report — May 21, 2025
Follow-Up
Date: May 21, 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 and life safety.
Complaint Details
The complaint investigation was triggered by the facility's failure of their third fire and life safety inspection and issuance of a Letter of Non-compliance by the Deputy State Fire Marshal. The investigation included review of fire inspection reports and interviews. The complaint number is 166726.
Findings
The facility was found to have no deficiencies during the follow-up inspection and meets the Assisted Living Facility licensing requirements. Previous deficiencies related to fire and life safety were corrected.
Deficiencies (3)
WAC 388-78A-2040 Other requirements. The Assisted Living Facility failed to ensure compliance with the Washington State Patrol Office of State Fire Marshal when it failed follow-up fire and life safety inspections, placing 67 residents, staff, and visitors at risk.
IFC 904.13.5.2 (2021) Extinguishing System Service. Deficiencies were found on the report; the facility is upgrading the wet system to UL300.
National Fire Protection Association 80 Fire/Smoke Dampers Inspection and Testing. Fire/smoke damper inspection paperwork was not provided and needs to be performed and documented.
Report Facts
Total residents: 67
Resident sample size: 2
Licensed beds: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hauk | Complaint Investigator | Conducted the on-site verification and investigation |
| Louis Wakefield-Larson | NHA, QTRIL, COO | Administrator who signed the Plan of Correction and attestation statements |
Inspection Report — May 20, 2025
Life Safety
Date: May 20, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire protection inspection at the facility.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following the inspection.
Deficiencies (7)
IFC 405.2 (2021) Records shall be maintained of required emergency evacuation drills including identity of the person conducting the drill, date and time, notification method, employees participating, number evacuated, special conditions, problems, weather, and time to complete evacuation.
IFC 603.5.2 (2021) Relocatable power taps and current taps shall be directly connected to a permanently installed receptacle.
IFC 606.3.3 (2021) Hoods, grease-removal devices, fans, ducts and other appurtenances shall be cleaned at required intervals.
IFC 701.6 (2021) The owner shall maintain an inventory of all required fire-resistance-rated construction and ensure it is visually inspected annually and properly repaired or replaced as needed.
IFC 705.2.4 (2021) Swinging fire doors shall close from the full-open position and latch automatically.
IFC 903.5 (2021) Sprinkler systems shall be tested and maintained in accordance with Section 901.
IFC 904.13.5.2 (2021) Automatic fire-extinguishing systems shall be serviced at least every six months and after activation by qualified individuals with certificates forwarded to the fire code official.
Inspection Report — Apr 24, 2025
Follow-Up
Date: Apr 24, 2025
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 related to food sanitation.
Findings
The follow-up inspection on 04/24/2025 found no deficiencies; all previously cited issues regarding food sanitation were corrected.
Deficiencies (1)
WAC 388-78A-2305 Food sanitation. The assisted living facility must manage food and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service. The facility failed to ensure one of two ice machines remained clean and free of splash and spray from beverages or other liquids, placing 42 of 66 residents at risk for foodborne illness.
Report Facts
Residents at risk: 42
Total residents: 66
Sample size: 9
Inspection Report — Dec 16, 2024
Complaint Investigation
Date: Dec 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that a staff member spoke aggressively to another staff member in front of a resident at the Assisted Living Facility.
Complaint Details
The complaint alleged that Named Staff #1 spoke aggressively to Named Staff #2 in front of a Named Resident. The investigation confirmed the aggressive speech but found no emotional harm to the resident. The facility suspended the staff member and investigated. Additionally, the investigation found that Staff B worked without an active credential, resulting in a citation.
Findings
The investigation found that the aggressive speech occurred but did not cause emotional harm to the resident. The facility followed policy by suspending the staff member and investigating. However, a citation was issued because one staff member worked with expired credentials, placing all 63 residents at risk.
Deficiencies (1)
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure credentials were active for 1 of 3 sampled staff, placing 63 residents at risk of receiving care from uncredentialled staff. The staff member provided care without an active credential from September through December 2024.
Report Facts
Total residents: 63
Resident sample size: 2
Days Staff B provided care: 49
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number 101425 to determine compliance with Assisted Living Facility requirements.
Complaint Details
This complaint investigation referenced complaint number 101425. The deficiencies related to background checks and coordination of care were substantiated as violations.
Findings
The facility was found not in compliance with licensing laws and regulations due to deficiencies including failure to complete a national fingerprint background check for a staff member and failure to coordinate care with a Primary Care Physician for a resident. The report includes a consultation on unsafe storage of toxic solutions. The facility must correct deficiencies within the timeframe accepted by the department.
Deficiencies (2)
WAC 388-78A-24642 Background checks National fingerprint background check. The facility failed to ensure that 1 of 3 sampled staff members completed a national fingerprint background check, placing all 68 residents at risk from unknown criminal background history.
WAC 388-78A-2350 Coordination of health care services. The facility failed to coordinate care with a Primary Care Physician to discontinue a treatment order for a resolved skin issue for 1 resident, resulting in unnecessary treatments being documented and performed.
Report Facts
Residents in the facility: 68
Sampled residents: 10
Sampled staff members: 3
Inspection Report — Aug 3, 2023
Life Safety
Date: Aug 3, 2023
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility on 08/03/2023.
Findings
All violations noted during previous related inspections have been corrected. The current inspection resulted in an Approved status with no open deficiencies.
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