Inspection Report
Annual Inspection
Capacity: 102
Deficiencies: 22
Oct 1, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from 2023-2025 with deficiency history and complaint investigations.
Findings
Across multiple inspections from 2023 to 2025, the facility was found out of compliance with various regulations including failure to report suspected abuse, incomplete disaster plan reviews, inadequate documentation of incidents and medication administration, and deficiencies in employee records and safety procedures. Several inspections found no deficiencies, while others cited multiple violations related to resident safety and regulatory compliance.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, some resulting in deficiencies related to abuse reporting, documentation, and compliance with regulations, while others found no deficiencies.
Deficiencies (22)
| Description |
|---|
| R9-10-803.J.1-6. Administration: Failed to report suspected abuse, neglect, or exploitation as required by A.R.S. § 46-454. |
| R9-10-819.A.2. Emergency and Safety Standards: Failed to ensure disaster plan was reviewed at least once every 12 months. |
| R9-10-819.D.2.a-f. Emergency and Safety Standards: Failed to document incident details when a resident needed medical services. |
| A. A manager shall ensure that: 8. A manager, caregiver, or employee provides evidence of freedom from infectious tuberculosis as specified in R9-10-113. |
| C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that a medication administered to a resident is documented in the resident's medical record. |
| A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented. |
| A. A manager shall ensure that: 5. An evacuation drill for employees and residents is conducted at least once every six months. |
| E. A manager of an assisted living center shall ensure that a fire inspection is conducted by a local fire department or the State Fire Marshal according to required time-frames. |
| A. A manager shall ensure that: 3. Garbage and refuse are stored in covered containers lined with plastic bags. |
| A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position. |
| A. A manager shall ensure that: 11. Poisonous or toxic materials are maintained in labeled containers in a locked area inaccessible to residents. |
| 36-420.04. Emergency responders; patient information: Failed to provide required written documentation to emergency responders for residents. |
| C. A manager shall ensure that food is protected from potential contamination. |
| A. A governing authority shall ensure compliance with A.R.S. § 36-411. |
| J. If a manager has a reasonable basis to believe abuse, neglect or exploitation has occurred, the manager shall comply with all reporting and investigation requirements. |
| C. A manager shall ensure that a caregiver or assistant caregiver documents the services provided in the resident's medical record. |
| C. A manager shall ensure that policies and procedures are established and implemented to protect resident health and safety including cardiopulmonary resuscitation training requirements. |
| E. A manager shall ensure documentation required by Article 8 is provided to the Department within two hours after a Department request. |
| C. A manager shall ensure personnel records include documentation of cardiopulmonary resuscitation training including demonstration. |
| C. A manager shall ensure personnel records include documentation of compliance with A.R.S. § 36-411(A) and (C). |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure residents provide evidence of freedom from infectious tuberculosis before or within seven calendar days after occupancy. |
Report Facts
Inspections on page: 12
Total deficiencies: 31
Complaint inspections: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celese Miller | Person Responsible | Named in multiple deficiency findings as responsible for corrective actions |
| E1 | Interviewed and acknowledged multiple deficiencies related to documentation and compliance | |
| E3 | Mentioned in abuse investigation and acknowledged issues with garbage storage and oxygen container security | |
| E8 | Employee whose tuberculosis documentation was deficient | |
| E10 | Acknowledged medication administration documentation issues | |
| E11 | Reported on employee shift times and disaster drills | |
| E5 | Personnel record reviewed for CPR training deficiencies | |
| E6 | Personnel record reviewed for compliance with fingerprint clearance and references |
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