Inspection Reports for East Valley Mansion Assisted Living
3368 E Sunnydale Dr, Queen Creek, AZ 85142, AZ, 85142
Back to Facility ProfileDeficiencies per Year
16
12
8
4
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Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 15
Mar 28, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-09 to 2025-03 with deficiency history and complaint investigations.
Findings
Across three inspections, multiple deficiencies were identified including failures in service plan updates, vaccination documentation, medication storage, staff training, and facility safety measures. Two complaint investigations were conducted, one with no deficiencies and one with multiple compliance issues.
Complaint Details
Two complaint investigations were conducted: one on 2025-03-28 with no deficiencies found, and one on 2024-12-27 with multiple deficiencies identified related to compliance issues.
Deficiencies (15)
| Description |
|---|
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and — Failed to ensure a written service plan was reviewed and updated at least once every three months for one resident. |
| 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); — Failed to ensure documentation of vaccination notification was present for one resident. |
| 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; — Failed to include skin maintenance in service plan for one resident. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 4. Strategies to ensure a resident's personal safety; 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan. — Failed to include required elements in service plan for one resident. |
| F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage; — Failed to ensure medications were stored in a locked and secure manner. |
| 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; — Failed to store poisonous or toxic materials in a locked and inaccessible area. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition — Failed to administer a fall prevention and recovery training program for all staff. |
| C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed. — Failed to ensure policies and procedures were reviewed and updated as required. |
| A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under the supervision of a manager or caregiver; — Failed to ensure assistant caregivers were supervised when interacting with residents. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures; — Failed to verify and document skills and knowledge of caregivers and assistant caregivers before providing services. |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. — Failed to ensure caregiver had current CPR and first aid certification. |
| E. A manager shall ensure that: 2. A calendar of planned activities is: a. Prepared at least one week in advance of the date the activity is provided, b. Posted in a location that is easily seen by residents, c. Updated as necessary to reflect substitutions in the activities provided, and d. Maintained for at least 12 months after the last scheduled activity; — Failed to maintain and post a calendar of planned activities. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration: a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist; — Failed to ensure medication administration policies were reviewed and approved by qualified professionals. |
| A. A manager shall ensure that: 1. A food menu: a. Is prepared at least one week in advance, c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served; — Failed to prepare and post food menu in advance. |
| D. A manager shall ensure that: 7. If not furnished by a resident, each sleeping area has: a. A bed, at least 36 inches in width and 72 inches in length, consisting of at least a frame and mattress that is clean and in good repair; — Failed to ensure one resident's sleeping area had a bed frame. |
Report Facts
Inspections on page: 3
Total deficiencies: 15
Complaint Inspections: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings related to service plan reviews, vaccination documentation, staff training, and policy acknowledgments | |
| E2 | Named in findings related to service plan reviews, medication storage, supervision of caregivers, and personnel records | |
| E3 | Named in findings related to supervision and personnel records | |
| E4 | Caregiver | Named in findings related to CPR certification, personnel records, and supervision |
| E5 | Named in interviews acknowledging deficiencies and policy issues |
Inspection Report
Enforcement
Deficiencies: 0
Oct 24, 2023
Visit Reason
State-compiled enforcement action report for EAST VALLEY MANSION ASSISTED LIVING detailing enforcement action #00112337 with associated penalty and payment schedule.
Findings
The document details an enforcement action completed on 11/16/2023 with a penalty amount of $1,250.00. No specific deficiencies or inspection findings are described in the report.
Report Facts
Total fines: 1250
Inspection Report
Enforcement
Deficiencies: 3
Sep 20, 2023
Visit Reason
The inspection was conducted due to enforcement concerns regarding unsupervised assistant caregivers, lack of documented verification of skills and knowledge for four employees, and one employee with expired CPR and first aid training.
Findings
The facility was found to have violations including unsupervised assistant caregivers, failure to verify skills and knowledge of caregivers, and an employee with expired CPR and first aid training. Civil fines totaling $1250 were assessed.
Deficiencies (3)
| Description |
|---|
| The manager failed to ensure assistant caregivers interacted with residents only under the supervision of certified caregivers. |
| The manager failed to ensure the skills and knowledge of four caregivers or assistant caregivers were verified and documented before providing physical health services. |
| The manager failed to ensure one employee had current CPR and first aid training; the training was expired. |
Report Facts
Civil fine amount: 1250
Civil fine amount: 500
Civil fine amount: 250
Civil fine amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reginya Woodetrick | Owner | Licensee/Director/Provider who signed the enforcement agreement |
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