Inspection Report
Life Safety
Deficiencies: 8
Dec 31, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 12/31/2024.
Findings
Multiple fire safety violations were observed including exposed wiring, open electrical terminations, blocked electrical panels, missing carbon monoxide alarms, and lack of required documentation for sprinkler system testing and fire door inspections.
Deficiencies (8)
| Description |
|---|
| Exposed wires found on soup warmer in kitchen. |
| Loose receptacle in kitchen entrance outside housekeeping room and broken receptacle cover found in kitchen. |
| Blocked electrical panels in 4th and 3rd floor PPE rooms. |
| Annual forward flow test paperwork for sprinkler system not provided. |
| Hood filters in kitchen need verification that no gaps are present allowing grease past filters. |
| Fire extinguisher found above 5 feet from floor. |
| Missing carbon monoxide alarms inside area connected to fossil fuel burning appliance. |
| Facility must identify and establish schedule for inspection of fire doors; annual inspection paperwork not provided. |
Report Facts
Next inspection scheduled date: Jan 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Signed as the inspecting official |
| Joman Nuqui | Maintenance Manager | Named as Owner's Representative and signed the report |
Inspection Report
Follow-Up
Census: 51
Deficiencies: 6
Jul 12, 2024
Visit Reason
The Department completed 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 Assisted Living Facility licensing requirements. Previous deficiencies related to privacy, tuberculosis screening, pet certification, service agreement planning, assisted living services, and resident unit furnishings were corrected.
Deficiencies (6)
| Description |
|---|
| Failure to ensure confidentiality of resident information in a public binder containing previous inspection results, placing 51 residents at risk of privacy violation. |
| Failure to ensure 1 of 5 staff members was screened for tuberculosis within three days of employment, placing 51 residents at risk of communicable disease exposure. |
| Failure to ensure 3 of 3 sampled pets were certified by a veterinarian to be free of diseases transmittable to humans, placing 51 residents at risk of communicable disease exposure. |
| Failure to develop the Negotiated Service Agreement for 1 of 7 sampled residents to include protocols for recognizing signs and symptoms of hyperglycemia and hypoglycemia, and failure to document a plan to monitor side effects of anticoagulation therapy, placing the resident at risk of harm. |
| Failure to ensure 1 of 1 sampled resident using an Adult Portable Bed Rail participated in assessments to identify need and ability to safely use the device, review of risks and benefits, and proper installation, placing the resident at risk of serious bodily harm. |
| Failure to maintain carpeting in 3 of 7 sampled resident apartments in a clean and sanitary manner, with significant dirt and staining observed, detracting from a homelike atmosphere. |
Report Facts
Residents sampled for review: 7
Current residents census: 51
Staff members reviewed for TB screening: 5
Pets sampled for certification: 3
Residents with deficient service agreements: 1
Residents using Adult Portable Bed Rail: 1
Resident apartments with unclean carpeting: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sunny Kent | Licensor | Department staff who conducted inspections |
| Scottie Sindora | ALF Licensor | Department staff who conducted inspections |
| Staff A | Executive Director | Interviewed regarding privacy breach, TB screening, pet certification, and bed rail issues |
| Staff B | Health & Wellness Director | Interviewed regarding service agreement deficiencies and acknowledged missing safety instructions |
| Staff F | Maintenance Manager | Interviewed regarding bed rail installation and carpet maintenance |
Inspection Report
Life Safety
Deficiencies: 7
Jan 24, 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
The facility was found to be non-compliant with multiple fire safety requirements, including inadequate working space around electrical panels, lack of documentation for annual fire wall inspection, missing documentation for fire damper inspections, semi-annual kitchen suppression system servicing, annual fire alarm system testing, smoke detector sensitivity testing, and absence of emergency lighting in the first floor emergency exit hallway.
Deficiencies (7)
| Description |
|---|
| Storage was found in front of electrical panels on multiple floors, violating required working space and clearance. |
| Facility unable to provide documentation that the annual fire wall inspection has been completed. |
| Facility unable to provide documentation for the 4 year fire and smoke damper inspection. |
| Facility unable to provide documentation for the semi-annual kitchen suppression system servicing. |
| Facility unable to provide documentation for the annual fire alarm system testing. |
| Facility unable to provide documentation for the required smoke detector sensitivity testing. |
| First floor emergency exit hallway to California Avenue has no emergency lighting in the path of egress. |
Report Facts
Next inspection scheduled: Feb 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Jesse Ward | Deputy State Fire Marshal | Named as the inspecting official conducting the fire safety inspection |
Inspection Report
Follow-Up
Census: 39
Deficiencies: 4
Jan 6, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 01/06/2023 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 related to licensing laws and regulations were corrected.
Complaint Details
The inspection was triggered by complaint numbers 55119 and 55117. The Department found the facility did not meet Assisted Living Facility requirements during the full inspection on 11/09/2022.
Deficiencies (4)
| Description |
|---|
| Failure to ensure 1 of 6 sampled staff was screened for tuberculosis within three days of employment, placing all 39 residents at risk of exposure. |
| Failure to have a system in place to evaluate, monitor, and follow prescribed treatment orders for a resident with open wounds, contributing to risk of preventable pressure ulcers. |
| Failure to ensure negotiated service agreements addressed specific needs for 3 of 7 sampled residents related to behavioral interventions and roles/responsibilities of family members. |
| Failure to dispose of expired food in walk-in refrigerator and freezer, placing residents at risk of foodborne illness. |
Report Facts
Sampled residents reviewed: 7
Current residents: 38
Former residents: 1
Staff screened for tuberculosis: 1
Residents with behavioral needs not addressed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Duran | Licensor | Department staff who did on-site verification and inspection |
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who did on-site verification and inspection |
| Jamie Singer | Field Manager | Signed letters and correspondence related to inspection and enforcement |
| Staff E | Caregiver hired 05/15/2022 with no TB screening documentation | |
| Staff H | Registered Nurse | Documented wound care and behavior issues for residents |
| Staff G | Medication Technician | Signed off on medication administration records |
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