Inspection Report
Complaint Investigation
Capacity: 97
Deficiencies: 11
Oct 14, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-02-02 to 2025-10-14 with deficiency history and complaint investigations.
Findings
Across all inspections, multiple deficiencies were identified including failures in staff training, safety and environmental controls, and documentation. Several complaint investigations found no deficiencies, while compliance inspections revealed issues with fall prevention training, fire inspections, and facility safety measures.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00147460 and 00147546 conducted on October 14, 2025; No deficiencies were found during the on-site investigation of complaints 00146801, 00146784, and 00146721 conducted on October 06, 2025; No deficiencies were found during the investigation of complaint #AZ00197928 conducted on July 18, 2023.
Deficiencies (11)
| Description |
|---|
| R9-10-806.A.4.a-b. Personnel: Failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services. |
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure means of exiting the facility for residents without keys or special knowledge included controls or alerts on doors. |
| R9-10-819.A.11. Environmental Standards: Poisonous or toxic materials were not maintained in labeled containers in a locked area inaccessible to residents. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. |
| E. A manager of an assisted living center shall ensure that a fire inspection is conducted by local fire department or State Fire Marshal according to required time-frame: Failed to ensure required fire inspection was conducted. |
| D. A manager shall ensure conspicuous posting of location of most recent Department inspection report and any plan of correction: Failed to ensure posting was conspicuous. |
| A manager shall ensure a plan is established, documented, and implemented for ongoing quality management including methods to make changes based on concerns: Failed to include method to make changes in quality management plan. |
| D. A manager shall ensure a current toxicology reference guide is available for use by personnel members: Failed to provide a current toxicology reference guide. |
| A. A manager shall ensure a food menu is conspicuously posted at least one calendar day before first meal served: Failed to post food menu. |
| A. A manager shall ensure meals and snacks are served according to posted menus: Failed to document meals and snacks served according to posted menus. |
| A. A manager shall ensure disaster plan is reviewed at least once every 12 months: Failed to review disaster plan annually. |
Report Facts
Inspections on page: 6
Total deficiencies: 12
Complaint inspections: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer West | Executive Director | Named in deficiency related to caregiver skills verification |
| Daniel Poulin | Maintenance Manager | Named in deficiencies related to door alert systems and chemical cart safety |
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