Inspection Report
Capacity: 112
Deficiencies: 13
Oct 7, 2025
Visit Reason
State-compiled facility profile showing 22 inspections from 2024-03 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, several deficiencies were found including failure to maintain current CPR/First Aid certifications for staff, incomplete emergency responder documentation, lack of documentation of preventive actions after resident incidents, failure to document services provided, pest control issues, and resident rights violations. Many complaint investigations found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted with most finding no deficiencies; however, some complaint inspections found deficiencies related to documentation, resident rights, and pest control.
Deficiencies (13)
| Description |
|---|
| R9-10-806.A.10. Personnel: Failed to ensure personnel records included current first aid and CPR certification for caregivers. |
| A.R.S. § 36-420.04.C. Emergency responders; patient information: Failed to provide emergency responders with all required resident information. |
| R9-10-818.D.2.a-f. Emergency and Safety Standards: Failed to document actions taken to prevent future incidents after resident injuries. |
| R9-10-810.B.1. Resident Rights: Failed to ensure a resident was treated with dignity, respect, and consideration. |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: Failed to ensure residents provided required TB documentation. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes frequency of assisted living services: Failed to include frequency of services in resident plans. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who is confined to a bed or chair because of inability to ambulate: Not fully detailed. |
| F. When medication is stored by an assisted living facility, a manager shall ensure medication is stored in a separate locked area: Not fully detailed. |
| A. A manager shall ensure that the premises and equipment are free from conditions causing physical injury: Not fully detailed. |
| R9-10-120. Opioid Prescribing and Treatment: Failed to document patient need and effect of opioid administration: Not fully detailed. |
| C. A manager shall ensure that a caregiver documents the services provided in the resident's medical record: Failed to document services provided, including night checks. |
| B. A manager shall ensure that a resident is treated with dignity, respect, and consideration: Failed to treat resident with dignity and respect, including issues related to cockroach infestation. |
| A. A manager shall ensure a pest control program is implemented and documented: Failed to maintain effective pest control program, resulting in severe cockroach infestation. |
Report Facts
Inspections on page: 22
Total deficiencies: 14
Complaint inspections: 19
Total capacity: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dora Carreon Moreno | Executive Director | Named in deficiencies related to CPR/First Aid certification, emergency responder documentation, and service plan documentation |
| Vanessa Borges | HR, Business Coordinator | Named in deficiency related to CPR/First Aid certification |
| Akemi Hughes | Health & Wellness Coordinator | Named in deficiency related to emergency responder documentation |
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