4 Reports
Inspection Report — Aug 30, 2025
Enforcement
Date: Aug 30, 2025
Visit Reason
Civil monetary penalty, action 00134351 (invoice INV-288695), assessed 30 August 2025.
Findings
A $500.00 penalty was assessed and paid in full on 31 July 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — May 12, 2025
Annual Inspection
Date: May 12, 2025
Visit Reason
On-site compliance (annual) inspection of an Assisted Living Home conducted on May 12, 2025.
Findings
This inspection found eight deficiencies related to staff training, resident rights, medical record protection, medication administration, food safety, and environmental safety. Plans of correction were provided for all deficiencies.
Deficiencies (8)
A.R.S. § 36-420.01.A — The facility failed to ensure a training program for all staff on fall prevention and fall recovery included initial and continued competency training. Documentation for continued training was missing for sampled personnel.
R9-10-113 — The chief administrative officer failed to ensure annual training on recognizing signs and symptoms of tuberculosis was provided to all personnel sampled. Documentation was missing for three employees.
R9-10-806 — The manager failed to ensure a caregiver provided current documentation of first aid training before providing assisted living services. One personnel record lacked first aid certification despite valid CPR certification.
R9-10-810 — The manager failed to ensure resident or representative consent was obtained before photographing the resident. One resident's medical record lacked a photographic consent form.
R9-10-811 — The manager failed to protect a resident's medical record from loss, damage, or unauthorized use. An open cabinet door exposed medical records during inspection.
R9-10-816 — The manager failed to ensure medication administration complied with medication orders. A resident was administered Colace 100mg twice daily instead of once daily as ordered.
R9-10-817 — The manager failed to ensure food stored was free from spoilage and contamination. A leaking, uncovered syrup bottle covered in ants was found in the kitchen.
R9-10-819 — The manager failed to ensure the premises and equipment were free from conditions that could cause physical injury. The leaking syrup bottle in the kitchen posed such a risk.
Report Facts
Deficiencies cited: 8
Inspection Report — Jul 19, 2023
Annual Inspection
Date: Jul 19, 2023
Visit Reason
On-site compliance (annual) inspection of an Assisted Living Home conducted on July 19, 2023.
Findings
The inspection found seven deficiencies related to documentation, food safety, disaster planning, and storage of toxic materials. Plans of correction were provided for all deficiencies.
Deficiencies (7)
The manager failed to ensure that a required documented pre-admission determination was completed within 90 days before or on the day the individual was accepted, posing a health and safety risk.
The manager failed to ensure two of three sampled residents' written service plans were signed and dated by the resident or representative and the manager as required.
The manager failed to ensure a resident's medical record contained documentation of notification of the availability of the pneumonia vaccination within the past 12 months, posing a health and safety risk.
The manager failed to ensure foods requiring refrigeration were maintained at 41° F or below; the refrigerator temperature was observed at 44.8° F, posing a health and safety risk.
The manager failed to ensure the disaster plan was reviewed and documented at least once every 12 months, posing a safety risk.
The manager failed to ensure an employee disaster drill was conducted and documented on each shift at least once every three months; no documentation was found for the second shift, posing a safety risk.
The manager failed to ensure poisonous or toxic materials were stored in a locked area; chemicals were found unlocked in a kitchen cabinet accessible to residents.
Report Facts
Deficiencies cited: 7
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