Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Life Safety
Deficiencies: 14
Oct 27, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Aegis Living Kirkland residential care facility on 10/27/2025.
Findings
Multiple fire safety code violations were identified, including issues with power taps, extension cords, appliance connections, fire door operations, sprinkler system maintenance, smoke detector sensitivity, fire department connection testing, carbon monoxide detection, means of egress continuity, emergency power illumination, door opening force, delayed egress locking systems, and bolt locks. All violations were marked as corrected or pending correction.
Deficiencies (14)
| Description |
|---|
| Relocatable power taps not listed in accordance with UL 1363 and UL 498A. |
| Extension cords used as substitute for permanent wiring and not properly listed or labeled. |
| Gas-fired commercial cooking appliances on casters not properly connected or tethered to building piping. |
| Opening protectives in fire-resistance-rated assemblies and smoke barriers not properly inspected and maintained. |
| Swinging fire doors do not close and latch automatically from full-open position. |
| Automatic sprinkler system not installed or maintained in accordance with NFPA 13 and Section 901. |
| Smoke detector sensitivity testing documentation not provided. |
| Fire department connection hydro testing documentation missing or failed; repairs pending. |
| Carbon monoxide detection not installed in resident rooms with forced air gas heating system. |
| Means of egress blocked by outdoor furniture when exiting memory care activity room. |
| Emergency power illumination fails to activate in kitchen and near room 202 during power failure. |
| Excessive force required to open courtyard side emergency door; door unable to fully open due to gate dragging on sidewalk. |
| Delayed egress locking systems missing signage on memory care unit courtyard door and memory care activity room. |
| Manually operated flush bolts or surface bolts present on courtyard side emergency door and kitchen door used for egress. |
Report Facts
Next inspection scheduled: Nov 26, 2025
Next inspection scheduled: Sep 11, 2025
Force to unlatch door: 15
Force to unlatch door by rotation: 28
Force to open interior swinging egress doors: 5
Force to open other swinging doors: 30
Force to move door to full open: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Hansen | Maintenance Director | Signed as Owner or Authorized Representative on 10/27/2025 inspection report |
| Brandon G. Brown | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on both 10/27/2025 and 08/12/2025 inspection reports |
| Angela F. Marks | General Manager | Signed as Owner or Authorized Representative on 08/12/2025 inspection report |
Inspection Report
Follow-Up
Census: 37
Deficiencies: 8
Jun 18, 2025
Visit Reason
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 Assisted Living Facility licensing requirements. Previous deficiencies related to service agreement planning and food sanitation were corrected.
Deficiencies (8)
| Description |
|---|
| Failed to update service plans for 2 of 5 sampled residents (Resident 5 and Resident 6), placing them at risk for unmet care needs and diminished quality of life. |
| Failed to follow required sanitation procedures in the main facility kitchen, placing all 37 residents at risk of consuming contaminated food and contracting food borne illnesses. |
| Failed to ensure 3 of 9 sampled care staff completed all required trainings including first aid and continuing education. |
| Failed to submit Washington state name and date of birth background check for 1 contracted staff within one business day after start date. |
| Failed to complete required tuberculosis (TB) skin testing for 3 of 14 sampled staff and failed to obtain chest X-ray documentation for 2 of 3 sampled staff. |
| Failed to implement nurse delegation services for 1 sampled resident (Resident 5), placing the resident at risk of harm from potential medication errors. |
| Failed to update service plans for 5 of 8 sampled residents, including inaccurate code status documentation, placing residents at risk for unmet care needs and diminished quality of life. |
| Failed to follow proper sanitation procedures in the main kitchen, including hair restraint and handwashing violations, placing all residents at risk of foodborne illness. |
Report Facts
Residents sampled: 37
Residents sampled: 5
Residents sampled: 7
Residents present: 32
Deficiencies cited: 8
Staff sampled: 14
Staff sampled: 9
Days late: 56
Days late: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Yip | ALF Licensor | Department staff who did on-site verification |
| Thomas Forkgen | ALF Licensor | Department staff who did on-site verification |
| Laurie Anderson | Community Field Manager | Signed follow-up inspection letter |
| Staff W | Care Manager | Named in nurse delegation and service plan deficiencies |
| Staff H | Lead Medication Care Manager | Named in nurse delegation and training deficiencies |
| Staff C | Care Manager | Named in training and tuberculosis testing deficiencies |
| Staff E | Medication Care Manager | Named in training and background check deficiencies |
| Staff O | Business Office Manager | Interviewed regarding background check and training deficiencies |
| Staff P | Agency Caregiver | Named in background check deficiency |
| Staff U | Life Enrichment Director / Culinary Service Director | Named in food sanitation and hair restraint deficiencies |
| Staff V | Lead Cook | Named in handwashing deficiencies |
| Staff Q | Registered Nurse Delegator | Named in nurse delegation deficiency |
| Staff R | Regional Health Services Director | Interviewed regarding service plan deficiencies |
Inspection Report
Enforcement
Census: 37
Deficiencies: 2
Apr 24, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the assisted living facility to assess compliance and enforce civil fines based on previously cited deficiencies.
Findings
The facility failed to update service plans for two residents and did not follow required sanitation procedures in one kitchen, placing residents at risk for unmet care needs and foodborne illnesses. These deficiencies were uncorrected from a prior citation dated February 25, 2025.
Deficiencies (2)
| Description |
|---|
| Failure to update service plans for two residents, risking unmet care needs and diminished quality of life. |
| Failure to follow required sanitation procedures in one kitchen, risking contaminated food and foodborne illnesses for all 37 residents. |
Report Facts
Civil fine amount: 400
Civil fine amount: 300
Total civil fines: 700
Resident count at risk: 37
Residents with outdated service plans: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Anderson | Field Manager | Contact person for plan of correction and enforcement communication |
| Matt Hauser | Compliance Specialist | Signed enforcement letter |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Sep 10, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by a failed Fire Marshal inspection.
Findings
The facility failed a third Fire Marshal inspection due to multiple fire safety violations, placing all 42 residents at risk. A Statement of Deficiency was issued and a citation was written.
Complaint Details
The complaint was related to a failed Fire Marshal inspection. The investigation substantiated the allegations, resulting in a citation and Statement of Deficiency issued on 09/12/2024.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure all 42 residents resided in a safe environment approved by the State Fire Marshal, resulting in fire safety violations and unsafe environmental conditions. |
Report Facts
Total residents: 42
Citation issue date: Sep 10, 2024
Statement of Deficiency issue date: Sep 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karri Hernandez | Community Complaint Investigator | Conducted the on-site verification and investigation |
| Laurie Anderson | Field Manager | Signed the Statement of Deficiencies and correspondence |
| Staff A | Director of Operation | Provided statements regarding facility's non-compliance and corrective plans |
Inspection Report
Re-Inspection
Deficiencies: 4
Sep 3, 2024
Visit Reason
An unannounced Fire and Life Safety Code re-inspection was conducted at Aegis Living of Kirkland by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with all applicable codes.
Findings
The inspection found that all violations noted during previous related inspections had been corrected except for a few remaining violations including failed fire damper shows, a capped sprinkler head in the dining room, missing documentation for sprinkler system tests and inspections, and deficiencies in the kitchen suppression system. Several other fire safety requirements were corrected at the time of re-inspection.
Deficiencies (4)
| Description |
|---|
| The facilities fire damper shows 3 failed. |
| The dining room on the first floor has a sprinkler head that is capped. |
| The facility was unable to provide documentation for: 3 year full flow trip test, Forward flow test, Quarterly sprinkler inspections. |
| The facilities kitchen suppression report shows deficiencies. |
Report Facts
Deficiencies cited: 4
Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Oct 24, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 10/24/2023 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected as listed in the report.
Report Facts
Residents reviewed: 7
Staff requiring Respiratory Protection Program: 36
Staff hired: 54
Sampled residents for negotiated service agreement deficiencies: 7
Sampled residents for lockable space deficiency: 2
Staff requiring TB skin test: 7
Staff with late TB test administration: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Failed to complete timely TB skin test; TB tests administered late | |
| Staff G | Failed to document reading of TB skin test results | |
| Staff I | Failed to administer one-step TB skin test within required timeframe | |
| Staff A | Health Services Director | Failed to administer one-step TB skin test; unaware of one-step TB test regulation |
| Staff C | Failed to administer one-step TB skin test; scheduled for CPR training | |
| Staff D | General Manager | Acknowledged late TB tests and lack of in-house fit test process |
| Staff J | Failed to complete fit testing for respirators |
Inspection Report
Life Safety
Deficiencies: 13
Jul 11, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire protection and safety codes.
Findings
Multiple deficiencies were cited related to fire-resistance construction, door operation, sprinkler system maintenance, extinguishing system service, fusible link maintenance, alarm system issues, smoke detector sensitivity, emergency lighting, exit signs, and fire door inspection and testing. The facility was disapproved due to these deficiencies.
Severity Breakdown
Changed 2: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to provide paperwork to identify and establish a schedule for inspection of fire-rated construction within 30 days and annual inspection by end of 2023. | — |
| Penetration found in resident laundry on the 2nd floor. | — |
| Soiled utility fire door not latching on the 2nd floor. | — |
| Quarterly sprinkler system inspections paperwork not provided. | — |
| First and second semi-annual servicing and annual replacement of fusible links paperwork not provided. | — |
| Facility needs to perform a heat survey for kitchen hood to determine fusible link required; currently four 450 degree links in place. | Changed 2 |
| Alarm system found in supervisor/silent status and smoke detector missing in resident room 104. | — |
| Sensitivity testing for smoke detectors paperwork not provided; sensitivity testing scheduled for 8/16/2023 at 9:00 am. | — |
| Missing smoke detector in resident laundry on the 2nd floor. | — |
| Emergency light broken in kitchen area. | — |
| Exit sign by stairway on 2nd floor by resident room 227 and exit sign outside kitchen on 1st floor missing or deficient. | — |
| Facility failed to provide paperwork for fire door inspection and testing including schedule and records. | — |
| Facility must identify and establish schedule for inspection of fire doors within 30 days and complete annual inspection by end of 2023. | — |
Report Facts
Provider Number: 2596
Next inspection scheduled on or after: Aug 10, 2023
Fusible links in place: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Hansen | Maintenance Director | Named as Owner's Representative and signatory on inspection report |
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
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