Inspection Report
Follow-Up
Census: 49
Deficiencies: 4
Nov 3, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to background checks, tuberculosis testing, and other licensing requirements were corrected.
Deficiencies (4)
| Description |
|---|
| Failure to ensure 1 of 6 staff had a Washington State name and date of birth background check submitted within one business day after hire. |
| Failure to ensure 1 of 2 staff had a valid Washington State name and date of birth background check completed every two years. |
| Failure to ensure 2 of 4 staff completed an approved Tuberculosis testing requirement. |
| Failure to ensure 3 of 4 staff were screened for Tuberculosis within three days of hire. |
Report Facts
Residents present during inspection: 49
Sample size for review: 7
Staff with background check deficiency: 1
Staff with expired background check: 1
Staff with tuberculosis testing deficiency: 2
Staff not screened for tuberculosis within 3 days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in background check and tuberculosis testing deficiencies |
| Staff F | Resident Care Partner | Named in background check deficiency |
| Staff C | Resident Care Partner | Named in tuberculosis testing deficiency |
| Staff B | Resident Care Partner | Named in tuberculosis testing deficiency |
| Staff D | Medication Technician | Named in tuberculosis testing deficiency |
| Staff G | Health & Wellness Director | Provided statements regarding deficiencies |
Inspection Report
Life Safety
Deficiencies: 10
Mar 3, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Brookdale Silver Lake residential care facility.
Findings
The inspection identified multiple fire safety violations including missing protective coverings on electrical panels, improperly restrained gas appliances, fire doors that do not close and latch properly, deficiencies in sprinkler system testing documentation, a missing locking device on a fire alarm power breaker, a non-operational carbon monoxide alarm, emergency exit door latching issues, and lack of secondary power for emergency exit signs.
Deficiencies (10)
| Description |
|---|
| Breaker missing in electrical panel K without protective coverings. |
| Electrical outlets without faceplates exposing inner electrical fixtures in multiple locations. |
| Storage items blocking access to the electrical panel in the electrical room. |
| Gas appliances on casters in the kitchen are not limited by a restraining device. |
| Fire rated doors from Claire dining room and Bridge den to corridor do not close and latch from fully open position. |
| Annual sprinkler testing had deficiencies not corrected; facility unable to provide documentation for quarterly sprinkler inspections. |
| Power breaker #7 in panel LS for fire alarm system is missing locking device. |
| Carbon monoxide alarm did not operate when tested in the Bridge dining room. |
| Emergency exit door from Bridge dining room has latching devices requiring double action to open. |
| Installed emergency exit sign in staff lounge lacks secondary power source for illumination during primary power loss. |
Report Facts
Next inspection scheduled date: Apr 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
| Rullie Constantino | Facility representative signing the inspection documents |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Sep 19, 2024
Visit Reason
The investigation was conducted due to a complaint that a Named Resident went missing from a secured Assisted Living Facility.
Findings
The Assisted Living Facility failed to follow its policy on accounting for residents, resulting in one resident exiting through a furnace room exit door unnoticed and being found offsite. A citation was issued for noncompliance with policies and procedures.
Complaint Details
The complaint involved a Named Resident who went missing from the secured facility. The investigation substantiated that staff failed to ensure the resident was included in the headcount, violating policy and placing the resident at risk of abuse, neglect, and financial exploitation.
Deficiencies (1)
| Description |
|---|
| Failure to implement policy on 'Elopement Risk' accounting for residents who leave the premises, resulting in a resident going missing and being found offsite. |
Report Facts
Total residents: 47
Resident sample size: 3
Citation count: 1
Alarm lapse duration (minutes): 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wesler Dumecquias | Community Complaint Investigator | Investigator who conducted the complaint investigation |
| Kimberley Ripley | Field Manager | Signed follow-up inspection letter confirming no deficiencies on 11/12/2024 |
Inspection Report
Life Safety
Deficiencies: 13
Mar 11, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire safety and life safety code requirements.
Findings
The inspection identified multiple fire safety violations including use of multiplug adapters without overcurrent protection, unmaintained fire-resistance rated construction, blocked fire doors, inoperative door-closing coordinators, sprinkler leaks, blocked suppression system pull station, deficient fire alarm system, non-functional smoke detectors, lack of carbon monoxide detector testing documentation, non-illuminated exit signs, and unsecured compressed gas cylinders.
Deficiencies (13)
| Description |
|---|
| Multipul adapter without over current protection in kitchen office area. |
| Facility unable to provide documentation of annual fire resistance rated construction material inspection. |
| 24 inch by 24 inch holes in ceiling of Claire building living room where leak repaired but ceiling fire barrier not repaired. |
| Several areas in Claire building near A6 missing rated walls or ceilings where leak happened on 1/14/24 and not repaired. |
| Fire rated door from Clare Den to corridor blocked open with chair preventing door closing and latching. |
| Fire rated door from Bridge country kitchen to corridor blocked open with chair preventing door closing and latching. |
| Fire rated cross corridor door near A1 had inoperative door-closing coordinator preventing doors from closing and latching. |
| Two sprinkler heads on patio from Clare living room disconnected due to sprinkler leak and not repaired. |
| Remote pull station for kitchen suppression system blocked by metal shelving. |
| Fire alarm system deficiencies noted and not corrected; three smoke detectors taped with plastic due to dust construction; non-working smoke detector in A6. |
| Facility unable to provide documentation for monthly carbon monoxide detector testing. |
| Internally illuminated exit signs near A4 and A1 would not illuminate when activation test button pushed. |
| Two oxygen cylinders in O2 storeroom not secured to prevent falling. |
Report Facts
Inspection date: Mar 11, 2024
Next inspection scheduled: Apr 10, 2024
Holes size: 24
Number of sprinkler heads disconnected: 2
Number of smoke detectors taped: 3
Number of oxygen cylinders unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Aurelio P. Constantino | Maintenance Director | Named as Owner's Representative and signed the report |
Inspection Report
Follow-Up
Census: 42
Deficiencies: 8
Jan 3, 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. Previously cited deficiencies related to food safety, background checks, staff training, tuberculosis testing, negotiated service agreements, and maintenance were corrected or addressed.
Deficiencies (8)
| Description |
|---|
| Failed to store food safely with uncovered open food items leading to possible cross contamination. |
| Failed to ensure 1 of 6 staff had updated background checks every two years. |
| Failed to ensure 1 of 6 staff completed facility orientation prior to providing care. |
| Failed to ensure 1 of 6 staff completed orientation and safety training. |
| Failed to ensure 2 of 6 staff completed required specialized dementia and mental health trainings. |
| Failed to ensure 2 of 6 staff were screened for tuberculosis within three days of employment. |
| Failed to provide services as negotiated for 1 of 7 residents, including oxygen therapy and weight monitoring. |
| Failed to provide a safe, sanitary, and well-maintained environment, including water pooling, dust accumulation, and unsecured cleaning supplies. |
Report Facts
Residents reviewed: 7
Staff reviewed: 6
Deficiencies cited: 8
Resident weight missing weeks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Mentioned in relation to food safety, maintenance issues, and tuberculosis testing. |
| Staff B | Caregiver | Failed to complete facility orientation prior to providing care. |
| Staff C | Caregiver | Failed to complete orientation and safety training and specialized dementia training; tuberculosis testing delayed. |
| Staff D | Caregiver | Notified and connected Resident 3 to oxygen device; discussed oxygen monitoring responsibilities. |
| Staff E | Caregiver | Failed to complete required mental health training. |
| Staff F | Caregiver | Did not have updated background check every two years. |
| Staff G | Business Office Manager | Provided information on staff background checks, orientation, and training. |
| Staff H | Caregiver | Unaware food needed to remain covered on trays and in cooler. |
| Staff I | Dining Services Coordinator | Acknowledged food safety issues due to being busy. |
| Staff J | Health and Wellness Director | Discussed oxygen therapy and weight monitoring deficiencies. |
| Jodi Condyles | ALF Licensor | Conducted on-site verification during follow-up inspection. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Feb 27, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a named resident had an injury fall in the Assisted Living Facility.
Findings
The investigation found that the facility failed to follow its fall policy for one resident who fell out of bed and did not receive a timely nursing assessment, resulting in a delay of treatment. A citation was issued for noncompliance with WAC 388-78A-2600 Policies and Procedures.
Complaint Details
The complaint alleged that the Named Resident had an injury fall in the Assisted Living Facility. The investigation substantiated that the facility failed to follow their fall policy, leading to delayed treatment and a 911 call. The resident was later hospitalized with right femur fractures and discharged on hospice care.
Deficiencies (1)
| Description |
|---|
| Failure to follow policy and procedure for a resident who fell out of bed and did not receive a nursing assessment, resulting in delayed treatment. |
Report Facts
Total residents: 42
Resident sample size: 3
Closed records sample size: 2
Compliance Determination Number: 20123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Banta | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
| Kimberley Ripley | Field Manager | Signed follow-up inspection letter confirming no deficiencies on 06/15/2023 |
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