Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Jul 29, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up inspection of the Assisted Living Facility to verify correction of previously identified deficiencies.
Findings
The follow-up inspection on 07/29/2025 found no deficiencies, indicating that the facility meets the Assisted Living Facility licensing requirements and corrected prior deficiencies.
Report Facts
Residents present during inspection: 42
Sample size for review: 7
Sample size for former residents: 0
Staff sample size: 6
Residents at risk: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did the on-site verification |
| Cathleen Davis | ALF Licensor | Department staff that inspected the Assisted Living Facility |
| Manfay Chan | Allied Health Field Manager | Signed the follow-up inspection letter |
| Hattie Russell | Administrator (or Representative) | Signed the plan of correction and compliance statement |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 23, 2025
Visit Reason
This document is the result of an Informal Dispute Resolution (IDR) process regarding disputed deficiencies identified in a Statement of Deficiencies (SOD) report dated 2025-06-10 for an Assisted Living Facility.
Findings
After review of all materials, oral statements, and records, the decision was made not to change the original SOD report dated 2025-06-10. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.
Report Facts
Correction timeframe: 45
Plan/Attestation Statement submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scotti Bower | IDR Program Manager | Author of the IDR results letter |
| Manfay Chan | Allied Health Field Manager | Recipient of Plan/Attestation Statement submissions |
Notice
Deficiencies: 0
Jun 10, 2025
Visit Reason
The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute a citation from a Statement of Deficiencies dated June 10, 2025.
Findings
The letter does not contain inspection findings but addresses the dispute of a specific citation (WAC 388-78A-2466) and provides instructions for submitting additional documentation prior to the scheduled IDR meeting.
Report Facts
Citation date: Jun 10, 2025
Scheduled IDR meeting date: Jul 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hattie Russell | Executive Director | Participant representing the facility in the IDR process |
| Glenna Wickett | District Director of Operations | Participant representing the facility in the IDR process |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 6, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously identified deficiencies related to medication services.
Findings
The follow-up inspection found no deficiencies, indicating that the previously identified medication service deficiencies were corrected.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did the On Site verification during the follow-up inspection |
Inspection Report
Life Safety
Deficiencies: 7
Dec 30, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Brookdale Puyallup South residential care facility to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple deficiencies including unsealed electrical panel openings, lack of documentation for fire-resistant construction inspections, failure to provide documentation for correction of 20 fire dampers that failed testing in January 2023, missing quarterly sprinkler inspection reports for Q3 and Q4 of 2024, missing semi-annual kitchen hood suppression system servicing reports, uncorrected horn strobe deficiencies from the September 20, 2024 annual service report, and an inoperable exit sign in the kitchen.
Deficiencies (7)
| Description |
|---|
| Panel K in kitchen has unsealed opening due to missing knockout on circuit #41. |
| Unable to provide last annual inspection of all fire-resistant-rated construction assemblies and records of repairs in the past 12 months. |
| Facility unable to provide documentation showing the 20 fire dampers that failed testing on January 2023 have been corrected and are now in compliance with NFPA 80. |
| Unable to produce quarterly inspection reports for Quarter 3 or Quarter 4 of 2024 for sprinkler systems. |
| Unable to provide reports showing that two semi-annual kitchen hood suppression system servicings were performed in the past 12 months. |
| Unable to provide documentation showing that horn strobe deficiencies identified in the September 20, 2024 annual service report have been corrected. |
| Exit sign in the kitchen found inoperable—replacement required. |
Report Facts
Fire dampers failed testing: 20
Quarterly inspection reports missing: 2
Semi-annual kitchen hood suppression system servicings missing: 2
Circuit number: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| D'Auna Jones | Maintenance Director | Signed as Owner or Authorized Representative on 09/17/2025 inspection |
| Jesse Ward | Deputy State Fire Marshal | Conducted inspection on 09/17/2025 |
| Damon Roberson | Deputy State Fire Marshal | Conducted inspection on 07/01/2025 |
| Lysandra Davis | Deputy State Fire Marshal | Conducted inspection on 12/30/2024 |
Notice
Deficiencies: 0
Brookdale Puyallup South 1702 60521 061025 Re Sched Ltr 0725
Visit Reason
This letter confirms the facility's request to reschedule an Informal Dispute Resolution (IDR) meeting to discuss disputed citations from a Statement of Deficiencies dated June 10, 2025.
Findings
The document does not contain inspection findings but addresses the scheduling and participants of the IDR process related to disputed citations.
Report Facts
Citation date: Jun 10, 2025
Scheduled IDR meeting date: Jul 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hattie Russell | Executive Director | Participant representing the facility in the IDR process |
| Glenna Wickett | District Director of Operations | Participant representing the facility in the IDR process |
| Laci Traulsen | Program Specialist 2/ Volunteer Coordinator | Author of the rescheduling letter |
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