Inspection Report
Complaint Investigation
Capacity: 55
Deficiencies: 11
Aug 6, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-05-04 to 2025-08-06 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to failure to report suspected abuse, environmental hazards, incomplete quality management programs, inadequate service plan implementation, and improper storage of toxic materials. Some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted, including complaints 00138582, 00136896, 00132707, 00121228, AZ00214236, AZ00210312, and AZ00190419, with deficiencies found in several complaint inspections.
Deficiencies (11)
| Description |
|---|
| R9-10-803.J.1-6. Administration: Manager failed to immediately report suspected abuse according to A.R.S. § 46-454. |
| R9-10-820.A.1.b. Environmental Standards: Manager failed to ensure premises were free from conditions causing physical injury, including torn and fraying carpet posing tripping hazards. |
| R9-10-804.1.a-e. Quality Management: Manager failed to establish and document a quality management program including methods to identify, document, and evaluate incidents. |
| R9-10-808.C.1.a-g. Service Plans: Manager failed to ensure caregivers provided and documented assisted living services according to residents' service plans for two of four sampled residents. |
| R9-10-815.C.7. Directed Care Services: Manager failed to ensure service plan included coordination of communications with resident's representative or family for one sampled resident. |
| R9-10-819.A.11. Environmental Standards: Manager failed to ensure poisonous or toxic materials were maintained in locked area inaccessible to residents. |
| A. A governing authority shall: 7. Notify the Department of manager changes and identify new manager's name and qualifications. |
| E. A manager shall ensure documentation required by this Article is provided to the Department within two hours after a Department request. |
| C. A manager shall ensure personnel records include documentation of compliance with A.R.S. § 36-411(A) and (C). |
| C. A manager shall not accept or retain an individual if the individual requires continuous medical services. |
| C. A manager shall not accept or retain an individual if the individual requires continuous nursing services unless compliant with A.R.S. § 36-401(C). |
Report Facts
Inspections on page: 6
Total deficiencies: 11
Complaint inspections: 6
Total capacity: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Estrada | Manager | Named in deficiencies related to abuse reporting and environmental hazards |
| Chardae Baker | Manager | Named in deficiencies related to quality management, service plans, environmental standards, and personnel records |
| E1 | Interviewed in multiple deficiencies as facility representative | |
| E4 | Personnel record reviewed in deficiency related to documentation compliance |
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