Inspection Reports for Brookdale Canyon Lakes

WA, 99337

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Inspection Report Complaint Investigation Census: 49 Deficiencies: 4 Apr 14, 2025
Visit Reason
The department conducted an unannounced on-site complaint investigation following notification by the Washington State Patrol Fire Protection Bureau that the facility failed two fire and life safety inspections.
Findings
The facility failed to maintain compliance with fire and life safety codes, including failure to provide required documentation for fire drills, failure of an exit sign, and lack of a secondary fuel source for the backup generator. These deficiencies placed residents, staff, and visitors at risk of harm in the event of a fire.
Complaint Details
Facility failed second fire and life safety inspection. The investigation was based on notification by the Washington State Patrol Fire Protection Bureau and included interviews, observations, and record reviews. Failed provider practice was identified and citations were written.
Deficiencies (4)
Description
Fire drills did not include all the required documentation.
Facility failed to provide documentation for the annual forward flow test.
One exit sign was not working.
The backup generator did not have a secondary fuel source.
Report Facts
Total residents: 49 Resident sample size: 2 Compliance Determination Completion Date: Completion dates mentioned are 04/18/2025 and 06/17/2025
Employees Mentioned
NameTitleContext
Robin BarnesAssisted Living Facility LicensorInvestigator who conducted the complaint investigation and off-site verification
Laura Williams-DavisALF Field ManagerSigned the follow-up inspection letter and statement of deficiencies
Inspection Report Life Safety Deficiencies: 15 Apr 9, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Brookdale Canyon Lakes residential care facility to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple deficiencies including incomplete fire drill documentation, missing breaker and protective covering in the kitchen power panel, unsafe use of extension cords, unilluminated exit signs, and lack of secondary fuel source for the backup generator. Several issues were corrected during the inspection, while others require further action.
Deficiencies (15)
Description
The fire drills documentation does not include all the required information.
The power panel in the kitchen was missing breaker #25 and did not have a protective covering installed.
Two extension cords were plugged into each other in the housekeeping laundry.
The internally illuminated exit sign near room 241 was not illuminated on normal power.
The level 1 backup generator has a natural gas fuel source but does not have a secondary fuel source as required by NFPA 110.
There were two 8 inch holes in the fire barrier in the basement crawlspace that have not been repaired.
The fire rated door to the 2nd floor elevator #3 has a broken door closure preventing the door from closing upon activation of the fire alarm.
Facility is unable to provide documentation for the annual forward flow test in accordance with NFPA 25.
There was a missing escutcheon plate from the sprinkler located near room 131.
Mixed standard response and quick response sprinkler heads were found in the dining room near the private dining room.
The walk-in type cooler with automatic defrost has ordinary temperature heads installed.
The required annual maintenance for the fire extinguisher in the water heat has not been completed in accordance with NFPA 10.
The required annual maintenance for the fire extinguisher near the staff lounge needs to be replaced.
The required annual maintenance for the fire extinguisher near room 15 needs to be replaced.
The power breaker #14 in the fire alarm system is missing a locking device.
Report Facts
Missing breaker number: 25 Holes in fire barrier: 2 Fire extinguisher maintenance issues: 3 Missing breaker number: 14
Employees Mentioned
NameTitleContext
Ryan CumptonMaintenance SupervisorNamed as Authorized Facility Representative on the 2025-04-09 inspection report
Jessica Teobaldino-MuttonDeputy State Fire MarshalConducted the 2025-04-09 inspection
Joseph GreenExecutive DirectorNamed as Authorized Facility Representative on the 2024-10-28 inspection report
Brandon G. BrownDeputy State Fire MarshalConducted the 2024-10-28 inspection
Inspection Report Life Safety Deficiencies: 15 Apr 9, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Brookdale Canyon Lakes residential care facility to evaluate compliance with fire protection and safety codes.
Findings
The inspection identified multiple violations including incomplete fire drill documentation, missing breaker and protective covering in the kitchen power panel, use of extension cords improperly, unilluminated exit signs, and deficiencies in fire alarm and sprinkler system maintenance. Several violations were corrected during the inspection.
Deficiencies (15)
Description
The fire drills documentation does not include all the required information.
The power panel in the kitchen was missing breaker #25 and did not have a protective covering installed.
There were 2 extension cords plugged into each other in the housekeeping laundry.
The internally illuminated exit sign near 241 was not illuminated on normal power.
The level 1 backup generator has a natural gas fuel source but does not have a secondary fuel source as required by NFPA 110.
There were two 8 inch holes in the fire barrier in the basement crawlspace that has not been repaired.
The fire rated door to the 2nd floor elevator #3 has a broken door closure preventing the door from closing upon activation of the fire alarm.
Facility is unable to provide documentation for the annual forward flow test in accordance with NFPA 25.
There was a missing escutcheon plate from the sprinkler located near room 131.
Mixed standard response and quick response sprinkler heads were found in the dining room near the private dining room.
The walk-in type cooler with automatic defrost has ordinary temperature heads installed.
The required annual maintenance for the fire extinguisher in the water heat has not been completed in accordance with NFPA 10.
The required annual maintenance for the fire extinguisher near the staff lounge needs to be replaced.
The required annual maintenance for the fire extinguisher near room 15 needs to be replaced.
The power breaker #14 in the fire alarm system is missing locking device.
Report Facts
Breaker number missing: 25 Holes in fire barrier: 2 Fire extinguisher maintenance frequency: 3 Inspection date: Apr 9, 2025 Inspection date: Oct 28, 2024 Next inspection scheduled: May 9, 2025
Employees Mentioned
NameTitleContext
Ryan CumptonMaintenance SupervisorNamed as Authorized Facility Representative on page 5
Joseph GreenExecutive DirectorNamed as Owner or Authorized Representative on page 9
Brandon G. BrownDeputy State Fire MarshalSigned inspection report on October 28, 2024
Jessica Teobaldino-MuttonDeputy State Fire MarshalSigned inspection report on April 9, 2025
Inspection Report Follow-Up Census: 53 Deficiencies: 3 Apr 7, 2025
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 the Assisted Living Facility licensing requirements. However, a prior full inspection on 02/05/2025 found multiple deficiencies related to staff training and supervision.
Deficiencies (3)
Description
Failure to ensure caregivers met the long-term care worker training requirements for 3 of 4 staff, placing residents at risk of being cared for by untrained staff.
Staff working unsupervised with residents without completing required mental health specialty training within the required timeframe.
Staff working unsupervised with residents without completing required dementia specialty training within the required timeframe.
Report Facts
Residents present during inspection: 53 Sample size for review: 7 Staff training delay days: 674 Staff training delay days: 60 Staff training delay days: 29
Employees Mentioned
NameTitleContext
Staff FMedication Technician (MT)Training completed 674 days late
Staff DCaregiverTraining not completed 60 days after required date
Staff BMedication Technician (MT)Training completed 29 days late
Tracy RamirezAssisted Living Facility LicensorDepartment staff who inspected the facility
Robin RainvilleAssisted Living Facility LicensorDepartment staff who inspected the facility and did off-site verification
Elizabeth HallAFH/ALF LicensorDepartment staff who inspected the facility
Inspection Report Re-Inspection Census: 49 Capacity: 53 Deficiencies: 3 Sep 10, 2024
Visit Reason
The visit was conducted as a reinspection following an annual fire and life safety inspection where multiple violations were found and one violation was not corrected from the previous inspection.
Findings
The Deputy State Fire Marshal found multiple violations during the annual life safety inspection and a failed practice was identified during the reinspection as one violation was not corrected. The facility failed to ensure compliance with fire safety regulations, specifically related to sprinkler system testing and documentation.
Complaint Details
The facility was in violation of several codes on the annual fire and life safety inspection. The reinspection found that the facility had not corrected one of the violations from the previous inspection. Failed practice identified.
Deficiencies (3)
Description
Failure to ensure compliance with Washington State Patrol Office of State Fire Marshal requirements after failing second Fire and Life Safety Inspection.
Failure to provide documentation of annual backflow testing within the past twelve months.
Failure to provide documentation of repairs and retesting of east wing fire sprinkler system backflow.
Report Facts
Total residents: 49 Total licensed beds: 53 Compliance Determination Number: 46885
Employees Mentioned
NameTitleContext
Melissa MilanezCommunity Complaint InvestigatorConducted the on-site verification and investigation
Joseph GreenAdministratorSigned the Plan of Correction attesting to corrective actions
Inspection Report Routine Deficiencies: 12 Jul 29, 2024
Visit Reason
The Office of the State Fire Marshal conducted a routine fire safety inspection at the Brookdale Canyon Lakes residential care facility on 07/29/2024.
Findings
The inspection identified multiple fire safety violations including improper storage of combustible materials, use of unfused multiplug adapters, failure to maintain fire-resistance-rated construction, lack of documentation for annual backflow testing and fire sprinkler system maintenance, outdated heat detectors, and missing documentation for smoke detector sensitivity testing.
Deficiencies (12)
Description
Combustible material stored in boiler rooms, mechanical rooms, electrical equipment rooms or fire command centers.
Use of multiplug adapters such as cube adapters and unfused plug strips prohibited by NFPA 70.
Relocatable power taps not directly connected to a permanently installed receptacle.
Failure to maintain inventory and visually inspect fire-resistance-rated construction annually.
Failure to inspect and maintain opening protectives in fire-resistance-rated assemblies and smoke barriers per NFPA 80 and NFPA 105.
Failure to inspect and maintain dampers protecting ducts and air transfer openings per NFPA 80 and NFPA 105.
Failure to provide documentation of annual backflow testing and repairs for fire sprinkler system.
Failure to provide documentation of semiannual servicing of automatic fire-extinguishing systems.
Failure to provide documentation of annual fire alarm service; heat detectors older than 15 years.
Failure to provide documentation of smoke detector sensitivity testing within past five years.
Failure to provide documentation of carbon monoxide alarm testing and maintenance.
Failure to provide documentation of emergency and standby power system maintenance and testing.
Report Facts
Heat detectors older than 15 years: 19 Next inspection scheduled: Aug 28, 2024
Employees Mentioned
NameTitleContext
Barbara MaierDeputy State Fire MarshalSigned inspection report and contact person.
Inspection Report Complaint Investigation Census: 39 Deficiencies: 1 Apr 18, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding missing medications at the assisted living facility.
Findings
The investigation found that staff were not following policies and procedures for counting controlled substances correctly and consistently, with incomplete controlled substance log entries and missing medication unreported. A failed provider practice was identified and citations were written.
Complaint Details
Complaint investigation was triggered by allegations of missing medications. The complaint number was 77743. The investigation confirmed failure to follow controlled substance handling policies and procedures.
Deficiencies (1)
Description
Facility failed to follow policies and procedures for counting controlled substances correctly and consistently, resulting in missing controlled medication going unnoticed.
Report Facts
Total residents: 39 Resident sample size: 3 Missing controlled substance count: 30 Date range of missing medication: Medication missing from 03/24/2023 until 04/09/2023
Employees Mentioned
NameTitleContext
Ronald HarrisInvestigatorConducted the complaint investigation
Robin RainvilleAssisted Living Facility LicensorPerformed on-site verification during follow-up inspection

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