Inspection Report Summary
The most recent inspection on October 1, 2025, identified deficiencies related to abuse reporting, disaster plan review, and incident reporting. Earlier inspections showed a pattern of similar issues involving documentation, emergency preparedness, and employee qualifications, with some enforcement actions and fines noted in mid-2023 and mid-2024. Complaint investigations were mostly unsubstantiated, with no deficiencies found in several cases, though a few investigations did cite deficiencies primarily around documentation and compliance with reporting requirements. Enforcement actions included fines related to failures in CPR training documentation and personnel records, all of which have been paid in full, and no license suspensions or immediate jeopardy findings were listed in the available reports. The inspection history suggests ongoing challenges with documentation and regulatory compliance, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
178% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Compliance (annual)
Capacity: 102
Deficiencies: 3
Date: Oct 1, 2025
Visit Reason
Found out of compliance with Settlement Agreement Term 5 related to maintaining substantial compliance with assisted living regulations; 3 deficiencies related to abuse reporting, disaster plan review, and incident reporting.
Findings
Found out of compliance with Settlement Agreement Term 5 related to maintaining substantial compliance with assisted living regulations; 3 deficiencies related to abuse reporting, disaster plan review, and incident reporting.
Deficiencies (3)
R9-10-803.J.1-6 — Abuse reporting documentation
R9-10-819.A.2 — Disaster plan review
R9-10-819.D.2.a-f — Incident reporting
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
No deficiencies found during investigation of complaints 00132091, 00132088, and 00105634.
Complaint Details
Investigation of complaints 00132091, 00132088, and 00105634
Findings
No deficiencies found during investigation of complaints 00132091, 00132088, and 00105634.
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
No deficiencies cited during investigation of complaints AZ00220157, AZ00221446, and AZ00221407.
Complaint Details
Investigation of complaints AZ00220157, AZ00221446, and AZ00221407
Findings
No deficiencies cited during investigation of complaints AZ00220157, AZ00221446, and AZ00221407.
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 0
Date: Nov 8, 2024
Visit Reason
No deficiencies cited during investigation of complaints AZ00218489, AZ00215901, and AZ00213724.
Complaint Details
Investigation of complaints AZ00218489, AZ00215901, and AZ00213724
Findings
No deficiencies cited during investigation of complaints AZ00218489, AZ00215901, and AZ00213724.
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
No deficiencies cited during investigation of complaints AZ00212130 and AZ00212180.
Complaint Details
Investigation of complaints AZ00212130 and AZ00212180
Findings
No deficiencies cited during investigation of complaints AZ00212130 and AZ00212180.
Enforcement Action
Enforcement
Fines: 1
Total: $4,900.00
Date: Jun 18, 2024
Summary
The enforcement resulted in a fine which has been fully paid as of the completed date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $4,900.00 | Fine related to enforcement action against the facility | Paid |
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 9
Date: Jun 6, 2024
Visit Reason
Found out of compliance with Settlement Agreement Terms #6 and #11 related to providing false/misleading information and failure to cure violations; 9 deficiencies cited.
Complaint Details
Investigation and compliance inspection related to Settlement Agreement Terms #6 and #11
Findings
Found out of compliance with Settlement Agreement Terms #6 and #11 related to providing false/misleading information and failure to cure violations; 9 deficiencies cited.
Deficiencies (9)
A. A manager shall ensure that: 8. Employee and volunteer qualifications documentation
C. Personnel records documentation
B. Medication administration documentation
A. Disaster drills conducted and documented
A. Evacuation drills conducted
E. Fire inspections conducted
A. Garbage and refuse storage
A. Oxygen containers secured
A. Poisonous/toxic materials stored securely
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 9
Date: Apr 18, 2024
Visit Reason
Found multiple deficiencies related to employee documentation, medication administration, disaster and evacuation drills, fire inspections, garbage storage, oxygen container security, and poisonous/toxic materials during investigation of complaint AZ00209015.
Complaint Details
Investigation of complaint AZ00209015
Findings
Found multiple deficiencies related to employee documentation, medication administration, disaster and evacuation drills, fire inspections, garbage storage, oxygen container security, and poisonous/toxic materials during investigation of complaint AZ00209015.
Deficiencies (9)
A. A manager shall ensure that: 8. Employee documentation
C. Personnel records documentation
B. Medication administration documentation
A. Disaster drills conducted and documented
A. Evacuation drills conducted
E. Fire inspections conducted
A. Garbage and refuse storage
A. Oxygen containers secured
A. Poisonous/toxic materials stored securely
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 2
Date: Mar 28, 2024
Visit Reason
Two deficiencies cited related to emergency responder documentation and food protection from contamination during investigation of complaints AZ00208244 and AZ00208259.
Complaint Details
Investigation of complaints AZ00208244 and AZ00208259
Findings
Two deficiencies cited related to emergency responder documentation and food protection from contamination during investigation of complaints AZ00208244 and AZ00208259.
Deficiencies (2)
36-420.04 Emergency responders documentation
C. Food protection from contamination
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
No deficiencies cited during investigation of complaints AZ00206966 and AZ00206994.
Complaint Details
Investigation of complaints AZ00206966 and AZ00206994
Findings
No deficiencies cited during investigation of complaints AZ00206966 and AZ00206994.
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
Two deficiencies cited related to governing authority compliance with A.R.S. § 36-411 and abuse reporting during investigation of complaint AZ00206670.
Complaint Details
Investigation of complaint AZ00206670
Findings
Two deficiencies cited related to governing authority compliance with A.R.S. § 36-411 and abuse reporting during investigation of complaint AZ00206670.
Deficiencies (2)
A. Governing authority compliance with A.R.S. § 36-411
J. Abuse, neglect, or exploitation reporting
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
One deficiency cited related to caregiver documentation of services during investigation of complaint AZ00195912.
Complaint Details
Investigation of complaint AZ00195912
Findings
One deficiency cited related to caregiver documentation of services during investigation of complaint AZ00195912.
Deficiencies (1)
C. Caregiver documentation of services
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jun 29, 2023
Summary
The facility failed to ensure proper CPR training documentation and personnel records for CPR training, posing a risk to resident health and safety. The Department was unable to determine substantial compliance during the inspection.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to establish and document policies and procedures to protect health and safety including CPR training and personnel records documentation. | Pending |
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jun 27, 2023
Summary
The enforcement resulted in a fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine associated with enforcement action #00113095 | Paid |
Inspection Report
Compliance (annual)
Capacity: 102
Deficiencies: 5
Date: May 22, 2023
Visit Reason
Found out of compliance with Settlement Agreement Terms #5 and #8 related to maintaining substantial compliance and compliance with A.R.S. § 36-411; 5 deficiencies cited related to policies and procedures, documentation, CPR training, and tuberculosis evidence.
Findings
Found out of compliance with Settlement Agreement Terms #5 and #8 related to maintaining substantial compliance and compliance with A.R.S. § 36-411; 5 deficiencies cited related to policies and procedures, documentation, CPR training, and tuberculosis evidence.
Deficiencies (5)
Policies and procedures to protect health and safety
Documentation required by Article 8 provided timely
CPR training documentation
Compliance with A.R.S. § 36-411(C)(2)
Evidence of freedom from infectious tuberculosis
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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