Inspection Reports for Golden Times LLC
13387 West Fargo Drive Surprise, AZ 85374, AZ, 85374
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Inspection Report
Annual Inspection
Capacity: 9
Deficiencies: 11
May 24, 2023
Visit Reason
State-compiled facility profile showing 1 annual compliance inspection from 2023 with deficiency history
Findings
The May 24, 2023 annual compliance inspection found 11 deficiencies related to staff training, management notification, residency agreements, service plans, and documentation compliance, posing various risks to resident health and safety.
Deficiencies (11)
| Description |
|---|
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. |
| A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;: Failed to notify the Department of a manager change as required. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.: Failed to ensure compliance with fingerprint clearance and reference checks for one employee. |
| A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;: Failed to ensure personnel record included required documentation of freedom from infectious tuberculosis for one employee. |
| D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours;: Failed to ensure residency agreement included whether manager or caregiver was awake during nighttime hours for one resident. |
| D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility, including terms of occupancy and other required elements: Failed to ensure updated residency agreement after change of ownership for one resident. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;: Failed to ensure written service plans included frequency of services for residents. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative;: Failed to ensure service plan was signed and dated by resident's representative for one resident. |
| E. A manager shall ensure that: 2. A calendar of planned activities is: d. Maintained for at least 12 months after the last scheduled activity;: Failed to maintain activity calendars for at least 12 months and provide them upon Department request. |
| 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: Failed to obtain required written medical determinations every six months for a resident confined to a wheelchair. |
| A. A manager shall ensure that: 3. Documentation of the disaster plan review required in subsection (A)(2) includes: c. A critique of the disaster plan review; and: Failed to ensure disaster plan review documentation included a critique and names of participating employees. |
Report Facts
Inspections on page: 1
Total deficiencies: 11
Total complaint inspections: 0
Total capacity: 9
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