Inspection Report Summary
The most recent inspection on October 10, 2025, found no deficiencies during an off-site review to change the facility’s licensed capacity. Prior inspections showed a pattern of deficiencies primarily related to caregiver training and documentation, service plans, medication and oxygen safety, and environmental controls such as securing poisonous materials. Several enforcement actions resulted in fines ranging from $250 to $3,250, all of which have been paid in full, but no license suspensions or immediate jeopardy findings were listed in the available reports. Complaint investigations were mostly unsubstantiated, though some substantiated cases involved issues with caregiver responsibilities and facility safety measures. The facility’s record shows some improvement with the most recent inspection free of deficiencies after a period of repeated citations and enforcement actions.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
197% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Modification
Capacity: 74
Deficiencies: 0
Date: Oct 10, 2025
Visit Reason
Off-site desktop review to change licensed capacity from 74 directed care to 21 directed care and 53 personal care; no deficiencies cited.
Findings
Off-site desktop review to change licensed capacity from 74 directed care to 21 directed care and 53 personal care; no deficiencies cited.
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jul 16, 2025
Summary
The enforcement resulted in a $500 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine associated with enforcement action #00130800 | Paid |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
One deficiency found related to failure to ensure means of exiting facility controlled or alerted employees.
Complaint Details
Complaints 00131852 and 00130714
Findings
One deficiency found related to failure to ensure means of exiting facility controlled or alerted employees.
Deficiencies (1)
R9-10-815.F.2.a-c. Directed Care Services — failure to ensure means of exiting facility controlled or alerted employees
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jun 6, 2025
Summary
A fine of $250 was imposed and has been paid in full, indicating resolution of the enforcement action.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine imposed as part of enforcement action | Paid |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 3
Date: Apr 24, 2025
Visit Reason
Three deficiencies found related to personnel documentation, service plans including level of service and medication storage.
Complaint Details
Complaint 00126264
Findings
Three deficiencies found related to personnel documentation, service plans including level of service and medication storage.
Deficiencies (3)
R9-10-806.A.8.a-b. Personnel — failure to ensure employee documentation of freedom from infectious tuberculosis
R9-10-808.A.3.b. Service Plans — failure to ensure written service plan included expected level of service
R9-10-808.A.3.f. Service Plans — failure to ensure service plan included medication storage and control
Enforcement Action
Enforcement
Fines: 2
Total: $500.00
Date: Apr 24, 2025
Summary
Two repeat deficiencies were identified posing health and safety risks to residents, resulting in civil fines totaling $500.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure employee documentation of freedom from infectious tuberculosis, posing potential TB exposure risk to residents. | — |
| $250.00 | Failure to ensure service plan included proper medication storage and control, posing health and safety risk. | — |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
One deficiency found related to failure to ensure policies and procedures were implemented to protect health.
Complaint Details
Cases 00124977, 00124970, 00124915, and 00124916
Findings
One deficiency found related to failure to ensure policies and procedures were implemented to protect health.
Deficiencies (1)
R9-10-803.C.1.g. Administration — failure to ensure policies and procedures implemented to protect health
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
No deficiencies found during investigation of complaints.
Complaint Details
Complaints 00123805, 00123713, and 00123809
Findings
No deficiencies found during investigation of complaints.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 3
Date: Mar 17, 2025
Visit Reason
Three deficiencies found related to food services, environmental standards including cleaning and poisonous materials storage.
Complaint Details
Complaints 00105482, 00105618, and 00121659
Findings
Three deficiencies found related to food services, environmental standards including cleaning and poisonous materials storage.
Deficiencies (3)
R9-10-817.C.1. Food Services — failure to ensure food stored was free from spoilage and safe for consumption
R9-10-819.A.1.a. Environmental Standards — failure to ensure premises and equipment cleaned and disinfected
R9-10-819.A.11. Environmental Standards — failure to ensure poisonous or toxic materials stored locked and inaccessible
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Mar 17, 2025
Summary
The facility was found to have a repeat deficiency from a prior inspection where poisonous or toxic materials were not properly secured, posing a risk to resident health and safety.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents, posing a health and safety risk. | — |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
One deficiency found related to caregiver responsibilities after resident accident or injury.
Complaint Details
Complaint AZ00217949
Findings
One deficiency found related to caregiver responsibilities after resident accident or injury.
Deficiencies (1)
D. Caregiver responsibilities — failure to ensure caregiver provided required documentation after resident accident or injury
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
No deficiencies found during investigation of complaints.
Complaint Details
Complaints AZ00214454 and AZ00213937
Findings
No deficiencies found during investigation of complaints.
Enforcement Action
Enforcement
Fines: 1
Total: $3,250.00
Date: Feb 20, 2024
Summary
The enforcement resulted in a fine of $3,250.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $3,250.00 | Fine associated with enforcement action #00111694 | Paid |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 10
Date: Jan 31, 2024
Visit Reason
Ten deficiencies found related to documentation, caregiver training, service plans, dignity and respect, medication storage, oxygen safety, and poisonous materials storage.
Complaint Details
Complaints AZ00205713 and AZ00205272
Findings
Ten deficiencies found related to documentation, caregiver training, service plans, dignity and respect, medication storage, oxygen safety, and poisonous materials storage.
Deficiencies (10)
E. Documentation required by Article 8 — failure to provide documentation to Department within two hours after request
A. Caregiver training documentation — failure to provide documentation of completion of approved caregiver training program
A. Assistant caregiver supervision — failure to ensure assistant caregiver interacted with residents under supervision
A. Caregiver skills verification — failure to verify and document caregiver skills and knowledge before providing services
A. CPR training documentation — failure to provide current documentation of cardiopulmonary resuscitation training
A. Written service plan signature — failure to ensure service plan signed and dated by manager
B. Resident dignity and respect — failure to ensure resident treated with dignity, respect, and consideration
F. Medication storage — failure to store medication in separate locked room, closet, cabinet, or self-contained unit
A. Oxygen container safety — failure to secure oxygen containers in upright position
A. Poisonous or toxic materials — failure to maintain in labeled containers in locked area inaccessible to residents
Enforcement Action
Enforcement
Fines: 3
Total: $3,250.00
Date: Jan 31, 2024
Summary
The enforcement resulted in civil fines totaling $3,250 for violations related to caregiver training certificates, skills verification, and CPR training deficiencies.
Fines & Penalties (3)
| Amount | Reason | Status |
|---|---|---|
| $2,500.00 | Five employees working as caregivers did not have caregiver training certificates. | — |
| $250.00 | Eight caregivers' skills and knowledge were not verified and documented before providing physical health services. | — |
| $500.00 | One employee's CPR training was invalid as it was online-only and did not include a return demonstration. | — |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 6
Date: Dec 27, 2023
Visit Reason
Six deficiencies found related to quality management, personnel records, service plans, medication administration, oxygen safety.
Complaint Details
Complaints AZ00200626, AZ00201265, AZ00203168, and AZ00203670
Findings
Six deficiencies found related to quality management, personnel records, service plans, medication administration, oxygen safety.
Deficiencies (6)
Quality management program — failure to establish, document, and implement ongoing quality management plan
R9-10-806.A.8.a-b. Personnel — failure to ensure employee documentation of freedom from infectious tuberculosis
R9-10-808.A.3.f. Service Plans — failure to ensure service plan included medication storage and control
R9-10-815.F.2.a-c. Directed Care Services — failure to obtain required documentation for resident acceptance
Medication administration compliance — failure to ensure medication administered per order
A. Oxygen container safety — failure to secure oxygen containers in upright position
Enforcement Action
Enforcement
Fines: 2
Total: $750.00
Date: Feb 6, 2023
Summary
The facility was found to have violations related to caregiver training certification and animal licensing, resulting in civil fines totaling $750.00.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | One employee, working as a caregiver, did not have a caregiver training certificate. | — |
| $250.00 | One dog residing in the facility did not have a license (repeat deficiency). | — |
Enforcement Action
Enforcement
Fines: 1
Total: $750.00
Date: Jan 24, 2023
Summary
The enforcement action was completed with a fine of $750.00 paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $750.00 | Fine associated with enforcement action #00113890 | Paid |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
No deficiencies found; two allegations unable to be substantiated.
Complaint Details
Complaint AZ00183156
Findings
No deficiencies found; two allegations unable to be substantiated.
Inspection Report
Annual Inspection
Capacity: 74
Deficiencies: 8
Date: Jan 4, 2023
Visit Reason
Eight deficiencies found related to quality management, caregiver training, service plans, vaccination notification, resident acceptance documentation, disaster drills, evacuation drill documentation, and pet licensing.
Findings
Eight deficiencies found related to quality management, caregiver training, service plans, vaccination notification, resident acceptance documentation, disaster drills, evacuation drill documentation, and pet licensing.
Deficiencies (8)
Quality management program — failure to establish, document, and implement ongoing quality management plan
A. Caregiver training documentation — failure to provide documentation of completion of approved caregiver training program
R9-10-808.A.3.f. Service Plans — failure to ensure service plan included medication storage and control
Vaccination notification documentation — failure to document notification of vaccination availability
R9-10-815.F.2.a-c. Directed Care Services — failure to obtain required documentation for resident acceptance
Disaster drills — failure to conduct and document disaster drills on each shift at least once every three months
Evacuation drill documentation — failure to maintain documentation including identification of residents needing assistance
Pet licensing — failure to ensure pets allowed in facility were licensed consistent with local ordinances
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