Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Enforcement
Deficiencies: 0
Aug 16, 2025
Visit Reason
State-compiled enforcement action summary for Garden Enclave Assisted Living Homes including penalty and payment details.
Findings
The document details an enforcement action with a financial penalty currently in process, including partial payment status and remaining balance.
Report Facts
Total fines: 1000
Payment amount paid: 250
Payment amount remaining: 750
Inspection Report
Complaint Investigation
Capacity: 5
Deficiencies: 16
May 9, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2024-02 to 2025-05 with deficiency history
Findings
Across three inspections, the facility had no deficiencies in two earlier inspections in 2024, but the most recent complaint and annual compliance inspection in May 2025 found 16 deficiencies related to documentation, resident care plans, tuberculosis screening, medication storage, and emergency preparedness.
Complaint Details
Complaint 00129767 was investigated during the May 9, 2025 inspection, which resulted in 16 deficiencies.
Deficiencies (16)
| Description |
|---|
| A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a standardized form for each resident including required emergency responder information. |
| R9-10-113.A.1-2. Tuberculosis Screening: Failed to establish, document, and implement tuberculosis infection control activities including annual risk assessment. |
| R9-10-803.D.1-4. Administration: Failed to conspicuously post location of most recent inspection report and plan of correction. |
| R9-10-804.3. Quality Management: Failed to maintain required quality management report for at least 12 months after submission. |
| R9-10-807.A.1-2. Residency and Residency Agreements: Failed to ensure residents provided evidence of freedom from infectious tuberculosis as required. |
| R9-10-807.B.1.a-b. Residency and Residency Agreements: Failed to ensure resident submitted documentation signed by medical practitioner or nurse regarding need for continuous medical or nursing services or restraints. |
| R9-10-807.D.1-10. Residency and Residency Agreements: Failed to ensure documented residency agreement was in place for a resident at acceptance. |
| R9-10-808.A.3.a. Service Plans: Failed to ensure resident's written service plan included description of medical or health problems including behavioral conditions. |
| R9-10-808.A.5.a. Service Plans: Failed to ensure written service plan was signed and dated by resident or representative. |
| R9-10-811.C.12. Medical Records: Failed to ensure resident medical records contained medication orders from medical practitioner for administered medications. |
| R9-10-811.C.18. Medical Records: Failed to ensure documentation of resident's orientation to exits was in medical record. |
| R9-10-811.C.9. Medical Records: Failed to ensure resident medical record contained signed residency agreement. |
| R9-10-815.C.6.a-b. Directed Care Services: Failed to ensure service plan included documentation of resident's weight or contraindication from medical practitioner. |
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure means of exiting facility provided access to outside area with alert to employees of resident egress. |
| R9-10-816.F.1. Medication Services: Failed to ensure medication was stored in a separate locked area used only for medication storage. |
| R9-10-818.A.2. Emergency and Safety Standards: Failed to ensure disaster plan was reviewed at least once every 12 months. |
Report Facts
Inspections on page: 3
Total deficiencies: 16
Complaint inspections: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Pagay | Licensee | Named as person responsible for all deficiencies in the May 9, 2025 inspection |
Inspection Report
Enforcement
Deficiencies: 2
May 9, 2025
Visit Reason
The inspection was conducted due to enforcement concerns related to violations found during a complaint inspection on November 19, 2024, resulting in civil fines and an enforcement agreement.
Findings
The facility was found to have deficiencies including failure to ensure a safe means of exiting the facility and failure to submit required medical documentation for residents, posing risks to resident safety and care.
Complaint Details
The deficiencies were repeat issues from a complaint inspection conducted on November 19, 2024.
Deficiencies (2)
| Description |
|---|
| The manager failed to ensure there was a means of exiting the facility that provided access to an outside area at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident. |
| The manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or registered nurse regarding continuous medical services or restraints for one of three residents reviewed. |
Report Facts
Civil fines total amount: 1000
Civil fine amount: 750
Civil fine amount: 250
Residents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Alma Reyes | Administrator | Licensee/Director/Provider who signed the enforcement agreement. |
| Dawn Butler | Bureau Chief | Attendee and signatory on enforcement agreement. |
| Thomas Salow | Assistant Director | Attendee and signatory on enforcement agreement. |
| Aaron Telles | Deputy Bureau Chief | Attendee and signatory on enforcement agreement. |
| Sean Thompson | Compliance Officer Supervisor | Attendee and signatory on enforcement agreement. |
Inspection Report
Enforcement
Deficiencies: 0
Jan 7, 2025
Visit Reason
State-compiled enforcement action report for Garden Enclave Assisted Living Homes detailing enforcement action #00109332 with associated invoice and payment schedule.
Findings
The document details an enforcement action in process with a financial penalty and partial payment status; no specific inspection deficiencies or findings are listed.
Report Facts
Total fines: 2500
Amount paid: 550
Amount remaining: 1950
Inspection Report
Enforcement
Deficiencies: 4
Nov 19, 2024
Visit Reason
The inspection was conducted to investigate regulatory compliance issues at Garden Enclave Assisted Living Homes, resulting in enforcement actions and civil fines for multiple violations.
Findings
The facility was found deficient in several areas including supervision of assistant caregivers, maintenance of personnel records, establishment and maintenance of medical records, and ensuring controlled egress of residents. These deficiencies posed health and safety risks and resulted in civil fines totaling $2,500.
Deficiencies (4)
| Description |
|---|
| The manager failed to ensure an assistant caregiver interacted with residents under supervision. |
| The manager failed to maintain personnel records for two of four employees sampled. |
| The manager failed to ensure a medical record was established and maintained for one of three residents sampled. |
| The manager failed to ensure a means of exiting the facility controlled or alerted employees of resident egress. |
Report Facts
Civil fines total amount: 2500
Civil fine amount: 500
Civil fine amount: 1000
Civil fine amount: 500
Civil fine amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nana Ansah | Administrator | Licensee/Director/Provider signing enforcement agreement |
| Dawn Butler | Bureau Chief | Attendee on enforcement agreement |
| Thomas Salow | Assistant Director | Attendee on enforcement agreement |
| Aaron Telles | Deputy Bureau Chief | Attendee on enforcement agreement |
| Sean Thompson | Compliance Officer Supervisor | Attendee on enforcement agreement |
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