Inspection Report
Life Safety
Deficiencies: 2
Mar 10, 2025
Visit Reason
The inspection was conducted by the Office of the State Fire Marshal to assess compliance with fire safety requirements, specifically testing and maintenance of the sprinkler system.
Findings
The facility failed to provide required documentation for the automatic sprinkler system, including the three-year dry system full flow trip test and the five-year fire department connection hydrostatic test. Previous violations noted during related inspections have been corrected as of the follow-up inspection on 04/15/2025.
Deficiencies (2)
| Description |
|---|
| Failed to provide documentation for the three-year dry system full flow trip test for the automatic sprinkler system. |
| Failed to provide documentation for the five-year fire department connection hydrostatic test for the automatic sprinkler system. |
Report Facts
Next inspection scheduled date: Apr 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Jennifer Huntley | Executive Director | Owner or Owner's Representative |
Inspection Report
Follow-Up
Census: 29
Deficiencies: 6
Jul 31, 2024
Visit Reason
Follow-up inspection conducted on 07/31/2024 to verify correction of previously cited deficiencies from inspections on 06/04/2024 and 06/06/2024.
Findings
The follow-up inspection found no deficiencies and the facility met Assisted Living Facility licensing requirements. Previous deficiencies related to tuberculosis testing, respiratory protection program, smoking area compliance, background checks, CPR/first aid training, and fingerprint background check processing were corrected or in the process of correction.
Deficiencies (6)
| Description |
|---|
| Failure to keep a record of tuberculosis testing for 1 of 6 sampled staff. |
| Failure to provide a full Respiratory Protection Program including N95 mask fit testing for 6 of 6 sampled staff. |
| Designated smoking area was not 25 feet away from building entrances, exits, or ventilation intakes. |
| Failure to complete Name and Date of Birth background checks with fingerprints within 30 days of hire for 1 of 6 sampled staff. |
| Failure to provide documentation of CPR and first aid training within 30 days of hire for 1 of 6 sampled staff. |
| Failure to complete final fingerprint background check within 120 days of hire for 1 of 6 sampled staff. |
Report Facts
Sampled residents: 5
Sampled former residents: 2
Sampled staff: 6
Sampled staff: 6
Sampled staff: 6
Days for provisional employment: 120
Days for tuberculosis screening: 3
Days for CPR training: 30
Distance for smoking area: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Interviewed regarding tuberculosis records, respiratory protection program, smoking area compliance, background checks, and CPR training |
| Staff B | Caregiver | Sampled staff missing tuberculosis testing record |
| Staff C | Caregiver | Sampled staff with delayed background check and fingerprinting; wore identifying badge during observation |
| Staff D | Caregiver | Sampled staff missing CPR/first aid training documentation; signed up for CPR training |
| Staff E | Sampled staff missing respiratory protection fit testing | |
| Staff F | Sampled staff missing respiratory protection fit testing | |
| Cathleen Davis | ALF Licensor | Department staff who did on-site verification |
| Cory Myers | ALF Complaint Investigator | Department staff who did on-site verification |
| Jennifer Huntley | Executive Director | Signed plan of correction letter |
Inspection Report
Life Safety
Deficiencies: 0
Apr 25, 2024
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility on 2024-04-25.
Findings
No violations were observed during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Signed the inspection report |
| Jennifer Huntley | Executive Director | Named as Owner's Representative |
Inspection Report
Life Safety
Deficiencies: 8
Apr 3, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Liberty Place residential care facility on 04/03/2023.
Findings
The facility was found to be noncompliant with multiple fire safety code requirements, including improper storage clearance near sprinkler heads, daisy-chaining of power strips, lack of semi-annual hood cleaning reports, missing documentation for sprinkler system forward flow test, missing semi-annual servicing reports for kitchen suppression system, missing annual replacement reports for fusible links, missing annual fire alarm inspection report, and a malfunctioning fire alarm annunciator panel.
Deficiencies (8)
| Description |
|---|
| Facility failed to maintain storage in holiday storage closet, storage too close to sprinkler head. |
| Facility failed to maintain power strips in maintenance shop, daisy-chaining. |
| Facility failed to provide semi-annual hood cleaning reports. |
| Facility failed to provide documentation showing forward flow test for the sprinkler system. |
| Facility failed to provide semi-annual servicing reports for the kitchen suppression system. |
| Facility failed to provide reports showing annual replacement of fusible links for kitchen suppression system. |
| Facility failed to provide annual inspection report for fire alarm system. |
| Facility failed to maintain fire alarm system, annunciator panel needs to be troubleshot. |
Report Facts
Next inspection scheduled date: May 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Murcia | Deputy State Fire Marshal | Inspector conducting the fire safety inspection |
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