Inspection Reports for
Suncreek Surprise LLC
16437 North 169th Drive, Surprise, AZ 85388, AZ, 85388
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Inspection Report — Nov 26, 2025
Enforcement
Date: Nov 26, 2025
Visit Reason
Civil monetary penalty, action 00147860 (invoice INV-306116), assessed 26 November 2025.
Findings
A $3,500.00 penalty was assessed and paid in full on 3 December 2025.
Report Facts
Penalty amount: 3500
Amount paid: 3500
Amount remaining: 0
Inspection Report — Sep 18, 2025
Annual Inspection
Date: Sep 18, 2025
Visit Reason
On-site complaint investigation of complaint 00143306 combined with an annual compliance inspection at an Assisted Living Home, conducted 18 September 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00143306 conducted on September 18, 2025.
Findings
This inspection found 17 deficiencies related to staff training, documentation, supervision, medication storage, and resident service plans. The facility failed to ensure proper fall prevention training, tuberculosis screening, accurate service plans, and secure medication storage among other issues.
Deficiencies (17)
A.R.S. § 36-420.01.A — The governing authority failed to administer a fall prevention and fall recovery training program for all staff, with one employee receiving training only after hire and not annually as required.
A.R.S. § 36-420.04.C — The manager failed to maintain standardized emergency responder forms for residents with required information, as forms for all eight residents were left blank until needed.
R9-10-113 — The chief administrative officer failed to provide annual tuberculosis training and education to two of three sampled employees and did not assess the facility’s TB exposure risk.
R9-10-806 — The manager failed to ensure an assistant caregiver interacted with residents only under supervision, as the assistant caregiver was observed unsupervised interacting with residents.
R9-10-806 — The manager failed to verify and document an assistant caregiver’s skills and knowledge before providing physical health services, with incomplete verification for one assistant caregiver.
R9-10-806 — The manager failed to maintain accurate documentation of caregivers’ and assistant caregivers’ work hours for at least 12 months, with inaccurate personnel schedules and medication administration times.
R9-10-806 — The manager failed to ensure caregivers provided evidence of freedom from infectious tuberculosis on or before the date services began for two of three sampled employees.
R9-10-806 — The manager failed to ensure an assistant caregiver received orientation specific to duties before providing assisted living services, with incomplete orientation documentation for one assistant caregiver.
R9-10-807 — The manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven days after occupancy, with missing TB risk assessment and symptom screening for one resident.
R9-10-808 — The manager failed to ensure residents’ service plans included the amount, type, and frequency of assisted living services, with discrepancies noted for two residents.
R9-10-808 — The manager failed to ensure caregivers provided assisted living services as specified in residents’ service plans, with one resident not receiving shower assistance as planned.
R9-10-808 — The manager failed to ensure caregivers documented services provided in residents’ medical records, with missing documentation of hydration and other services for two residents.
R9-10-811 — The manager failed to ensure residents’ medical records documented medication administration dates and times accurately, with medication given earlier than documented for seven residents.
R9-10-814 — The manager failed to include skin maintenance to prevent and treat injuries in the service plan for one resident receiving personal care services, despite daily assistance being provided.
R9-10-815 — The manager failed to ensure a means of exiting the facility for residents without keys was monitored or alerted staff, with an unidentified visitor leaving unnoticed and the front door key accessible to residents.
R9-10-817 — The manager failed to ensure medication was stored in a separate locked area used only for medication storage, with an unlocked medication cart and keys left in the lock multiple times.
R9-10-819 — The manager failed to ensure documentation of the date and time of a resident’s accident requiring medical services was accurate, with conflicting dates and times reported for the incident.
Report Facts
Deficiencies cited: 17
Complaints investigated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Manager | Manager responsible for multiple deficiencies including training, documentation, and supervision. |
| Staff #2 | Caregiver | Caregiver involved in tuberculosis training and documentation deficiencies. |
| Staff #3 | Assistant Caregiver | Assistant caregiver observed interacting with residents unsupervised and with incomplete orientation and skills verification. |
Inspection Report — Jun 30, 2023
Annual Inspection
Date: Jun 30, 2023
Visit Reason
On-site compliance (annual) inspection at an Assisted Living Home conducted on June 30, 2023.
Findings
Three deficiencies were found related to incomplete or inaccurate written service plans for residents, posing risks to resident care and service clarity.
Deficiencies (3)
The manager failed to ensure a written service plan included the correct level of service the resident received for one of two residents reviewed. This posed a risk as the service plan did not reinforce and clarify services to be provided.
The manager failed to ensure a written service plan included the amount, type, and frequency of assisted living services provided for one of two residents reviewed. This posed a risk if a resident's service plan did not include the services to be provided.
R9-10-808 — The manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections for one resident receiving directed care services. This posed a risk if the facility was unable to meet the resident's needs.
Report Facts
Deficiencies cited: 3
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