8 Reports
Inspection Report — Jul 13, 2026
Life Safety
Date: Jul 13, 2026
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved following this inspection.
Deficiencies (16)
IFC 315.2.1 (2021) - Storage shall be maintained 2 feet or more below the ceiling in nonsprinklered areas or 18 inches below sprinkler head deflectors. Exceptions apply for storage along walls in nonsprinklered areas or buildings with automatic sprinkler systems.
IFC 603.6 (2021) - Extension cords shall not be a substitute for permanent wiring and must be listed and labeled. They shall not be affixed to structures or extended through walls or floors and must be used only with portable appliances marked for indoor use.
IFC 606.4 (2021) - Gas-fired commercial cooking appliances on casters must be connected to piping systems with compliant appliance connectors and restrained to limit movement.
IFC 705.2 (2021) - Opening protectives in fire-resistance-rated assemblies and smoke barriers must be inspected and maintained to ensure fire doors and smoke draft control doors are not blocked or inoperable.
IFC 705.2.4 (2021) - Swinging fire doors shall close from the full-open position and latch automatically.
IFC 706.1 (2018) - Dampers protecting ducts and air transfer openings must be inspected, maintained, and securely attached or bonded to the construction without visible openings.
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 inspection certificates forwarded to the fire code official.
IFC 906.2 (2021) - Portable fire extinguishers shall be selected, installed, and maintained per NFPA 10 with exceptions for travel distance and inspection frequency.
IFC 907.8.3 (2021) - Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter with calibration tests performed as needed.
IFC 912.7 (2021) - Fire department connections shall be periodically inspected, tested, and maintained with records kept.
IFC 915.6 (2021 WAC) - Carbon monoxide alarms and detection systems must be maintained and replaced when inoperable or at end-of-life.
IFC 1003.6 (2021) - Means of egress travel paths shall not be obstructed or diminished in width or capacity by any building element or obstruction.
IFC 906.2 (2021) - Portable fire extinguishers must have monthly inspection records maintained.
IFC 1032.10 (2021) - Emergency lighting shall be maintained and inspected in accordance with applicable sections.
IFC 1203.4 (2021) - Emergency and standby power systems shall be maintained to supply service within required timeframes.
Report Facts
Next inspection scheduled: Jul 17, 2026
Inspection Report — Jun 17, 2026
Life Safety
Date: Jun 17, 2026
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire protection inspection at the facility.
Findings
The inspection found multiple fire and life safety deficiencies, many of which were corrected on site. However, several violations remained uncorrected, resulting in a disapproved status.
Deficiencies (33)
IFC 315.2.1 (2021) Storage shall be maintained 2 feet or more below the ceiling in nonsprinklered areas or 18 inches below sprinkler head deflectors. Ceiling clearance requirements and exceptions are specified.
IFC 603.6 (2021) Extension cords shall not substitute permanent wiring and must be listed and labeled. They shall not be affixed to structures or used outdoors if marked for indoor use only.
IFC 606.4 (2021) Gas-fired commercial cooking appliances on casters must be connected to piping with compliant connectors and restrained to limit movement.
IFC 705.2 (2021) Opening protectives in fire-resistance assemblies and smoke barriers must be inspected and maintained per NFPA standards. Fire doors and smoke doors must not be blocked or modified.
IFC 705.2.4 (2021) Swinging fire doors shall close from the full-open position and latch automatically.
IFC 706.1 (2018) Dampers protecting ducts and air transfer openings must be inspected and maintained, and damaged materials repaired or replaced.
IFC 903.5 (2021) Sprinkler systems shall be tested and maintained according to Section 901.
IFC 904.13.5.2 (2021) Automatic fire-extinguishing systems must be serviced at least every six months and after activation by qualified individuals with inspection certificates forwarded to the fire code official.
IFC 906.2 (2021) Portable fire extinguishers must be selected, installed, and maintained per NFPA 10 with exceptions for travel distance and inspection frequency.
IFC 1010.2.4 (2021) Locking devices are permitted on doors to balconies, decks, or exterior spaces of 250 square feet or less serving private office space.
IFC 1032.10 (2021) Emergency lighting shall be maintained and inspected per Sections 1031.10.1 and 1031.10.2.
IFC 1203.4 (2021) Emergency and standby power systems must be maintained to supply service within required timeframes for type and duration.
IFC 315.2.1 (2021) Obstruction of sprinkler in hallway 'A' Emergency Flashlight closet.
IFC 603.6 (2021) Extension cord in maintenance office.
IFC 606.4 (2021) Kitchen stove not tethered to wall.
IFC 705.2 (2021) Facility unable to provide documentation on fire door assembly annual inspection.
IFC 705.2.4 (2021) Fire emergency doors did not latch close from fully opened position in country kitchen and small TV room.
IFC 706.1 (2018) Facility unable to provide documentation on fire/smoke damper 4-year inspection.
IFC 903.5 (2021) Facility unable to provide documentation for annual sprinkler system, 5-year internal piping, 3-year dry system full flow trip, annual dry system trip, annual forward flow test, and quarterly sprinkler system inspections.
IFC 904.13.5.2 (2021) Facility unable to provide documentation for second semi-annual hood cleaning.
IFC 906.2 (2021) Multiple fire extinguishers missing monthly inspection records.
IFC 907.8.3 (2021) Facility unable to provide documentation for sensitivity testing of automatic fire alarm system.
IFC 912.7 (2021) Facility unable to provide documentation for 5-year FDC hydro testing.
IFC 915.6 (2021 WAC) Facility unable to provide documentation for carbon monoxide alarms detection testing and maintenance.
IFC 1003.6 (2021) Medical cart blocking an emergency exit in 'C' hall by room C8.
IFC 1404 (implied) All doors that are electrically controlled without delayed egress shall have a code posted within 6 feet of the door.
IFC 1404 (implied) Doors unlock upon loss of electrical power controlling the lock or lock mechanism and can be deactivated by a signal from a switch in an approved location.
IFC 1404 (implied) A system such as keypad and code must allow visitors, staff, and residents to exit with instructions posted within six feet of the door.
IFC 1404 (implied) Occupant load of exterior area shall not exceed 300 and maximum occupant load posted where required.
IFC 1404 (implied) A weatherproof telephone or two-way communication system shall be located adjacent to required exit access doors.
IFC 1404 (implied) Egress door locking device shall be readily distinguishable as locked and be key-operated locking device.
IFC 1404 (implied) Clear window or glazed door opening of at least 5 square feet shall be provided at each exit access door to determine occupancy.
IFC 1404 (implied) Readily visible durable sign posted on interior side of exit access door stating 'THIS DOOR TO REMAIN UNLOCKED WHEN THE OUTDOOR AREA IS OCCUPIED'.
Report Facts
Next inspection scheduled: Jul 17, 2026
Next inspection scheduled: May 15, 2026
Inspection Report — Nov 3, 2025
Follow-Up
Date: Nov 3, 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.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies cited in multiple WAC codes were corrected.
Deficiencies (5)
WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The facility failed to ensure one of six staff had a background check submitted within one business day of hire.
WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. The facility failed to ensure one of two staff had a valid background check completed every two years.
WAC 388-78A-2481 Tuberculosis Testing method Required. The facility failed to ensure two of four staff completed an approved tuberculosis test, placing all residents at risk for exposure to a communicable disease.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment.
WAC 388-78A-2468 Background checks Employment Conditional hire Pending results of Washington state name and date of birth background check. The facility failed to ensure one staff had a background check submitted within one business day of hire, placing residents at risk of being cared for by a staff person with a potentially disqualifying background.
Report Facts
Sampled residents: 7
Total residents: 49
Staff with missing background check: 1
Staff with missing biennial background check: 1
Staff missing tuberculosis testing: 2
Staff missing tuberculosis screening within three days: 1
Inspection Report — Apr 8, 2025
Life Safety
Date: Apr 8, 2025
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire safety inspection at the facility on 04/08/2025.
Findings
All violations noted during previous related inspections have been corrected. The facility was approved at this inspection.
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation after a Named Resident went missing from a secured Assisted Living Facility.
Complaint Details
The complaint involved a Named Resident who went missing from the facility after exiting through a furnace room exit door. The facility failed to follow its policy on resident head counts, leading to a citation for noncompliance. The investigation included interviews, observations, and record reviews.
Findings
The investigation found that the facility failed to follow its policy on accounting for residents, resulting in a resident exiting through a furnace room exit door unnoticed. A citation was issued for noncompliance with WAC 388-78A-2600 (2) (i) regarding policies and procedures.
Deficiencies (1)
WAC 388-78A-2600 (2) (i) - The assisted living facility failed to implement its policy on elopement risk by not supervising and accounting for residents who leave the premises, resulting in a resident exiting through the furnace room exit door unnoticed.
Report Facts
Total residents: 47
Resident sample size: 3
Lapse time: 25
Distance: 0.9
Inspection Report — Mar 11, 2024
Life Safety
Date: Mar 11, 2024
Visit Reason
The Office of the State Fire Marshal conducted a scheduled fire protection inspection at the facility on 03/11/2024.
Findings
The inspection identified multiple fire safety violations including unsecured compressed gas cylinders, blocked fire doors, damaged fire barriers, and non-functioning fire alarm components. The facility was disapproved due to these unresolved deficiencies.
Deficiencies (11)
IFC 604.4 2018 - Multiplug adapters such as cube adapters and unfused plug strips are prohibited. There was a multi-plug adapter without over current protection in the kitchen office area.
IFC 701.6 2018 WAC 51-54A - The owner must maintain an inventory and visually inspect fire-resistance-rated construction annually. Facility is unable to provide documentation of annual fire resistance rated construction material inspection.
IFC 703.1 2018 - Fire-resistance-rated construction and firestop systems must be maintained without openings. There were 24 inch by 24 inch holes in the ceiling of Claire building living room and several unrepaired rated walls or ceilings near A6 from a leak on 1/14/24.
IFC 705.2 2018 - Fire rated doors and smoke and draft control doors must not be blocked or obstructed. The fire rated door from Clare Den to corridor and the door from Bridge country kitchen to corridor were blocked open with chairs preventing closing and latching.
IFC 705.2.4 2018 - Swinging fire doors must close and latch automatically. The fire rated cross corridor door near A1 had an inoperative door-closing coordinator preventing closing and latching.
IFC 903.5 2018 - Sprinkler systems must be tested and maintained. Two sprinkler heads on the patio from Clare living room have been disconnected due to a leak and not repaired. The walk-in cooler with automatic defrost has ordinary temperature heads installed.
IFC 904.12.5.2 2018 - Automatic fire-extinguishing systems must be serviced and inspected. The remote pull station for the kitchen suppression system was blocked by metal shelving.
IFC 907.8 2018 - Fire alarm and detection systems must be maintained and tested. The fire alarm system had deficiencies not corrected including three smoke detectors taped with plastic and a non-working smoke detector in A6.
IFC 915.6 2018 - Carbon monoxide alarms must be maintained and replaced if inoperable. Facility is unable to provide documentation for monthly carbon monoxide detector testing.
IFC 1013.5 2018 - Internally illuminated exit signs must be labeled and illuminated at all times. Exit signs near A4 and A1 did not illuminate when activation test button was pushed.
IFC 5303.5.3 2018 - Compressed gas containers must be secured to prevent falling. Two oxygen cylinders in the O2 storeroom were not secured to prevent falling.
Report Facts
Holes in ceiling: 2
Smoke detectors taped: 3
Oxygen cylinders unsecured: 2
Inspection Report — Jan 3, 2024
Follow-Up
Date: Jan 3, 2024
Visit Reason
This is a follow-up inspection to verify correction of previously cited deficiencies at the Assisted Living Facility.
Findings
The follow-up inspection found no deficiencies and confirmed that all previously cited licensing law violations were corrected. The facility meets Assisted Living Facility licensing requirements.
Deficiencies (8)
WAC 246-215-03306 Preventing food and ingredient contamination -- Packaged and unpackaged food -- Separation, packaging, and segregation (2009 FDA Food Code 3-302.11). The facility failed to store food safely with uncovered open food items in the kitchen, risking cross contamination and foodborne illness.
WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid. The facility failed to ensure one staff member had a background check updated every two years, risking resident safety.
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure one staff member completed facility orientation prior to providing care, risking compromised resident care and safety.
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure one staff member completed orientation and safety training, placing residents at risk due to unqualified staff.
WAC 388-78A-2474 Training and home care aide certification requirements. The facility failed to ensure two staff completed required specialized dementia and mental health trainings, risking inadequate care for residents with these needs.
WAC 388-78A-2480 Tuberculosis Testing Required. The facility failed to ensure two staff were screened for tuberculosis within three days of hire, risking resident exposure to communicable disease.
WAC 388-78A-2160 Implementation of negotiated service agreement. The facility failed to provide required oxygen treatment and weight monitoring for one resident, placing them at risk for medical complications.
WAC 388-78A-3090 Maintenance and housekeeping. The facility failed to maintain a safe, sanitary, and well-maintained environment, including water pooling, dust-covered vents, and unsecured hazardous chemicals, risking resident safety and quality of life.
Report Facts
Sampled residents: 7
Total residents: 42
Staff count with deficiencies: 6
Resident weight missing weeks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Caregiver | Failed to have updated background check every two years |
| Staff B | Caregiver | Failed to complete facility orientation prior to providing care |
| Staff C | Caregiver | Failed to complete orientation and safety training and specialized dementia training |
| Staff E | Caregiver | Failed to complete required mental health training |
| Staff A | Executive Director | Failed to ensure tuberculosis screening within three days of hire |
| Staff D | Caregiver | Failed to ensure resident's oxygen device was turned on as prescribed |
| Staff G | Business Office Manager | Provided interview statements regarding staff training and background check deficiencies |
| Staff J | Health and Wellness Director | Provided interview statements regarding oxygen device and weight monitoring deficiencies |
Inspection Report — Feb 27, 2023
Complaint Investigation
Date: Feb 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding an injury fall of a Named Resident in the Assisted Living Facility.
Complaint Details
The complaint alleged that a Named Resident had an injury fall in the facility. The investigation included interviews, observations, and record reviews. It was determined that the resident fell from bed, was sleeping on the floor, and the facility failed to follow their fall policy, resulting in delayed treatment and a 911 call. The citation was issued for failure to follow policies and procedures.
Findings
The investigation found that the facility failed to follow its fall policy for one resident, resulting in a delay of treatment. A citation was issued for WAC 388-78A-2600 Policies and Procedures.
Deficiencies (1)
WAC 388-78A-2600 Policies and procedures. The Assisted Living Facility failed to follow their policy and procedure for one sampled resident who fell out of bed and did not receive a nursing assessment, causing a delay in treatment.
Report Facts
Total residents: 42
Resident sample size: 3
Closed records sample size: 2
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