Inspection Report
Complaint Investigation
Capacity: 138
Deficiencies: 11
Oct 1, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2024-04 to 2025-10 with deficiency history and complaint investigations.
Findings
Across four inspections, the facility had 11 deficiencies primarily related to documentation, resident care plans, food safety, disaster drills, premises cleanliness, and storage of hazardous materials. Several complaint investigations found no deficiencies, while others identified issues posing health and safety risks.
Complaint Details
The page includes complaint investigations for multiple complaint numbers across inspections, with some complaint inspections finding no deficiencies and others identifying multiple deficiencies related to resident care and facility operations.
Deficiencies (11)
| Description |
|---|
| A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document D. An assisted living center or assisted living home shall maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of the emergency. Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of documentation provided to an emergency responder. The deficient practice posed a risk if the Department was unable to verify the required documentation was provided during a resident emergency. |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for influenza (flu) according to A.R.S. 'a7 36-406(1)(d), which required the facility to make the vaccination available to the resident on site on a yearly basis; for two of seven sampled residents records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk. |
| F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; Based on observation, record review, and interview, the manager failed to ensure that a service plan for a resident who is receiving personal care services included the treatment of bruises, injuries, pressure sores, and infections, which posed a health and safety risk; for two of two sampled residents. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or Based on record review and interview, the manager failed to ensure that for one two sampled resident who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41'b0 F or below which posed a health and safety risk. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 6. Frozen foods are stored at a temperature of 0° F or below; and Based on observation and interview, the manager failed to ensure that frozen foods were stored at a temperature of 0'b0 F or below. |
| 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; Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented which posed a safety risk. |
| A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection. |
| A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents; Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were in a locked area and inaccessible to residents. |
| A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents; Based on observation and interview, the manager failed to ensure that combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. |
| A. A manager shall ensure that: 14. If pets or animals are allowed in the assisted living facility, pets or animals are: b. Licensed consistent with local ordinances; and Based on record review and interview the manager failed to ensure two sampled dog residing at the facility were licensed consistent with the local ordinances. |
Report Facts
Inspections on page: 4
Total deficiencies: 11
Complaint inspections: 4
Total capacity: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Plante | Executive Director | Named as person responsible in deficiency related to emergency responder documentation |
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