Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Life Safety
Deficiencies: 17
Apr 22, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility.
Findings
The inspection found multiple fire safety violations including improper use and listing of power taps, ventilation system issues, unsecured kitchen gas appliances, door operation problems, insufficient sprinkler heads, missing documentation for fire safety testing and maintenance, obstructed fire extinguishers, and confusing signage on emergency exits.
Deficiencies (17)
| Description |
|---|
| Room 204 had unfused power adapter. |
| Staff lounge had multiple power strips plugged into a power strip. |
| Use a extension cord in foyer near coffee pot. |
| Filters in kitchen hood system were not installed properly. |
| Kitchen gas appliances on wheels were not tethered to wall. |
| Ceiling penetrations near room 109 & 101. |
| Smoke barrier wall penetrations in properly sealed in first floor storage and near room 203. |
| Room 108 door would not properly latch. |
| Non sufficient amount of spare sprinkler heads and sprinkler wrench missing. |
| Documentation of 5 year hydro test unavailable. |
| Kitchen fire extinguisher obstructed by calendar. |
| Data room fire extinguisher mounted with improper hanger and height. |
| No documentation of monthly smoke detector testing. |
| No documentation of monthly carbon monoxide detector testing. |
| No documentation of monthly emergency light testing. |
| No documentation of annual 90 emergency light test. |
| Signage on stairwells obstructs and could be confusing that it is not an emergency exit. |
Report Facts
Inspection date: Apr 22, 2025
Next inspection scheduled: May 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Maria Damann | General Manager | Owner or Authorized Representative who signed the report |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 30, 2024
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 09/30/2024 as part of a compliance determination.
Findings
The inspection found no deficiencies in the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cristina Gonzalez | ALF Licensor | Department staff who did the inspection |
| Jodi Condyles | ALF Licensor | Department staff who did the inspection |
Inspection Report
Follow-Up
Census: 40
Deficiencies: 1
Apr 13, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiency related to failure to ensure staff were fit tested for N-95 masks was corrected.
Complaint Details
Complaint investigation found that the facility failed to follow infection prevention control practices by not ensuring 20 of 26 care staff were properly fit tested for N-95 masks, placing residents and staff at risk of COVID-19. The complaint was substantiated with citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staff were fit tested for N-95 masks before being assigned duties requiring their use, placing residents and staff at risk of COVID-19 infection. |
Report Facts
Total residents: 40
Resident sample size: 5
Care staff not fit tested: 20
Care staff fit tested: 6
Completion date: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Conducted complaint investigation and follow-up inspection |
| Jayne Hill | Field Manager | Field Manager overseeing complaint investigation and enforcement correspondence |
| Kimberley Ripley | Field Manager | Field Manager who signed follow-up inspection letter |
| Staff A | Interviewed staff who provided information on fit testing and training schedules |
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