15 Reports
Inspection Report — Mar 12, 2026
Enforcement
Date: Mar 12, 2026
Visit Reason
Civil monetary penalty, action 00142052 (invoice INV-327202), assessed 12 March 2026.
Findings
A $350.00 penalty was assessed and paid in full on 20 February 2026.
Report Facts
Penalty amount: 350
Amount paid: 350
Amount remaining: 0
Inspection Report — Dec 23, 2025
Complaint Investigation
Date: Dec 23, 2025
Visit Reason
On-site complaint investigation of complaints 00149546, 00142137, 00153809, and 00147758 at an Assisted Living Center, conducted 23 December 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00149546, 00142137, 00153809, and 00147758 conducted on December 23, 2025.
Findings
No deficiencies were found during this inspection.
Report Facts
Complaints investigated: 4
Inspection Report — Dec 2, 2025
Enforcement
Date: Dec 2, 2025
Visit Reason
Civil monetary penalty, action 00145504 (invoice INV-306516), assessed and completed 2 December 2025.
Findings
A $2,150.00 penalty was assessed and paid in full on 2 December 2025.
Report Facts
Penalty amount: 2150
Amount paid: 2150
Amount remaining: 0
Inspection Report — Aug 20, 2025
Annual Inspection
Date: Aug 20, 2025
Visit Reason
On-site complaint investigation of complaint 00141183 combined with an annual compliance inspection at an Assisted Living Center, conducted 20 August 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00141183 conducted on August 19, 2025.
Findings
The inspection found eight deficiencies related to personnel records, manager certification and notification, tuberculosis documentation, service plan updates, vaccination notifications, and disaster plan documentation. Plans of correction were provided for all deficiencies.
Deficiencies (8)
R9-10-803 — The governing authority failed to make a documented good faith effort to contact previous employers to obtain information relevant to an employee's fitness to work, posing a safety risk to residents.
R9-10-803 — The governing authority failed to designate, in writing, a qualified manager with a valid certificate or temporary certificate for periods when the facility had no manager, posing a risk to resident health and safety.
R9-10-803 — The governing authority failed to notify the Department of a change in manager and identify the new manager's name and qualifications, preventing the Department from ensuring a qualified manager was maintained.
R9-10-806 — The manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis on or before the date services began, posing a potential TB exposure risk to residents.
R9-10-806 — The manager failed to ensure a personnel record was available for one employee, preventing verification of required information and posing a risk to compliance determination.
R9-10-808 — The manager failed to ensure written service plans were reviewed and updated at least every three months for two residents receiving directed care services, risking unclear service provision.
R9-10-811 — The manager failed to ensure residents' medical records contained documentation of notification of availability of influenza and pneumonia vaccinations, posing a potential illness risk.
R9-10-819 — The manager failed to ensure the disaster plan review included the time of review, a critique, and recommendations for improvement, risking inadequate disaster preparedness.
Report Facts
Deficiencies cited: 8
Inspection Report — Jul 16, 2025
Complaint Investigation
Date: Jul 16, 2025
Visit Reason
On-site complaint investigation of complaints 00104451, 00136706, 00104908, and 00104450 at an Assisted Living Center, conducted 16 July 2025.
Complaint Details
The following deficiency was found during the on-site investigation of complaints 00104451, 00136706, 00104908, and 00104450 conducted on July 16, 2025:
Findings
The inspection found one deficiency related to the failure to designate a qualified manager in writing. A plan of correction was provided and accepted.
Deficiencies (1)
R9-10-803 — The governing authority failed to designate, in writing, a manager with a valid assisted living facility manager certificate or temporary certificate. This deficiency posed a risk to ensuring compliance with applicable rules.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 18, 2025
Complaint Investigation
Date: Mar 18, 2025
Visit Reason
On-site complaint investigation at an Assisted Living Center, conducted 18 March 2025.
Findings
The inspection found eight deficiencies related to management policies, quality management, personnel records, residency agreements, medical records, medication administration, and emergency drills. No evidence text was provided for any deficiency.
Deficiencies (8)
Policies and procedures — The facility failed to provide evidence of established, documented, and implemented policies covering required areas including job descriptions, orientation, complaint submission, CPR training, first aid, behavior response, staffing, resident rights, and termination of residency.
Quality management program — The facility failed to provide evidence of an established, documented, and implemented ongoing quality management program including methods to identify, document, evaluate incidents, collect and evaluate data, take action on concerns, and report to the governing authority.
R9-10-115 — The facility failed to provide evidence that personnel records for employees or volunteers included required documentation such as qualifications, education, orientation, licenses, tuberculosis freedom, CPR and first aid training, and compliance with statutory requirements.
Residency agreement — The facility failed to provide evidence of a documented residency agreement including terms of occupancy, services provided and available for additional fees, policies on nighttime caregiver presence, refund policies, termination procedures, complaint process, and manager's signature.
Medical records — The facility failed to provide evidence that a medical record was established and maintained for each resident according to statutory requirements.
Medication administration — The facility failed to provide evidence that medications administered to residents were done so in compliance with medication orders.
Disaster drills — The facility failed to provide evidence that disaster drills for employees were conducted on each shift at least once every three months and documented.
Evacuation drills — The facility failed to provide evidence that evacuation drills for employees and residents were conducted at least once every six months and included all individuals on the premises except those medically exempted and sufficient caregivers to ensure safety.
Report Facts
Deficiencies cited: 8
Inspection Report — Nov 19, 2024
Enforcement
Date: Nov 19, 2024
Visit Reason
Civil monetary penalty, action 00110224 (invoice INV-330028), assessed 19 November 2024.
Findings
A $2,800.00 penalty was assessed and paid in full by 2 April 2026.
Report Facts
Penalty amount: 2800
Amount paid: 2800
Amount remaining: 0
Inspection Report — Oct 10, 2024
Complaint Investigation
Date: Oct 10, 2024
Visit Reason
On-site complaint investigation of complaint AZ00217123 at an Assisted Living Center, conducted 10 October 2024.
Complaint Details
This revised Statement of Deficiencies supersedes the previous SOD for Event ID 444X11. An on-site investigation of complaint AZ00217123 was conducted on October 10, 2024, resulting in four cited deficiencies.
Findings
The inspection found four deficiencies related to staff training, manager certification, and documentation of services. These deficiencies posed risks to resident safety and compliance with regulations.
Deficiencies (4)
36-420.01 — The manager failed to ensure the facility administered a fall prevention and fall recovery training program that included initial and continued competency training for all staff sampled.
Governing authority failed to designate a manager with a valid assisted living facility manager certificate or temporary certificate, leaving the facility without a certified manager since September 20, 2024.
Manager failed to ensure a caregiver provided current documentation of first aid and adult CPR training for one of four personnel records reviewed, posing a risk during emergencies.
Manager failed to ensure caregivers documented services provided in residents' medical records for three residents, resulting in missing documentation for multiple dates and services.
Report Facts
Deficiencies cited: 4
Inspection Report — Sep 24, 2024
Enforcement
Date: Sep 24, 2024
Visit Reason
Civil monetary penalty, action 00110542 (invoice INV-257542), assessed 24 September 2024.
Findings
A $1,500.00 penalty was assessed and paid in full on 5 December 2024.
Report Facts
Penalty amount: 1500
Amount paid: 1500
Amount remaining: 0
Inspection Report — Sep 4, 2024
Annual Inspection
Date: Sep 4, 2024
Visit Reason
On-site complaint investigation of complaint AZ00215292 combined with an annual compliance inspection at an Assisted Living Center, conducted 4 September 2024.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00215292 conducted on September 4, 2024.
Findings
This inspection found eight deficiencies related to unavailable documentation including policies and procedures, quality management program, personnel records, residency agreements, medical records, medication administration, and disaster and evacuation drills. The Department was unable to determine substantial compliance due to lack of access to required documents.
Deficiencies (8)
The manager failed to ensure that policies and procedures were established and documented, as the facility's policies and procedures were not available for review and were locked in an inaccessible office.
The manager failed to ensure a plan was established, documented, and implemented for an ongoing quality management program, as the quality management documentation was not available for review and was locked in an inaccessible office.
R9-10-115 — The manager failed to ensure personnel records were available for each employee requested, as records were locked in an inaccessible office and not available for review.
The manager failed to ensure documented residency agreements were in place for two of seven residents sampled, as the agreements were not available for review and were locked in an inaccessible office.
The manager failed to ensure a medical record was maintained for each resident according to statute, as one resident's medical record was not available for review and was locked in an inaccessible office.
The manager failed to ensure medication was administered in compliance with orders, as one resident did not receive medications as ordered due to awaiting refills and medication unavailability.
The manager failed to ensure disaster drills for employees were conducted on each shift at least once every three months and documented, as disaster drills were not available for review and were locked in an inaccessible office.
The manager failed to ensure evacuation drills for employees and residents were conducted at least once every six months, as evacuation drills were not available for review and were locked in an inaccessible office.
Report Facts
Deficiencies cited: 8
Inspection Report — Sep 21, 2023
Annual Inspection
Date: Sep 21, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00189555, AZ00190550, AZ00191111, AZ00191749, AZ00191750, and AZ00191751 at an Assisted Living Center, conducted on September 20 and 21, 2023.
Complaint Details
The deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00189555, AZ00190550, AZ00191111, AZ00191749, AZ00191750, and AZ00191751 conducted on September 20 and 21, 2023.
Findings
The inspection found seven deficiencies related to staff training, caregiver compliance, documentation, notification of emergencies, and facility cleanliness. Plans of correction were provided for all deficiencies.
Deficiencies (7)
36-420.01 — The facility failed to develop and administer a fall prevention and fall recovery training program for all staff, as documentation of training for one staff member was not available and the manager was unaware the training was required.
The governing authority failed to ensure compliance with A.R.S. § 36-411 by allowing a caregiver to work with an invalid fingerprint clearance card, which was expired and not properly submitted, posing a risk to vulnerable residents.
The manager failed to ensure that a resident submitted required documentation dated within 90 days before acceptance, indicating the resident required continuous medical services beyond the facility's licensed scope.
The manager failed to ensure caregivers documented services provided in residents' medical records according to their service plans, resulting in discrepancies in frequency and lack of verification for multiple residents.
The manager failed to ensure immediate notification to a resident's emergency contact or primary care provider following an accident or injury requiring medical services, with no documentation available for review.
The manager failed to ensure documentation of accidents or injuries included required details such as date, description, observers, actions taken, notifications, and prevention measures for a resident who had an emergency.
The manager failed to ensure the premises and equipment were cleaned and disinfected to prevent illness or infection, with observed debris, dirt, and feces-like smears in residents' bedrooms and bathrooms.
Report Facts
Deficiencies cited: 7
Complaints investigated: 6
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