Inspection Report
Follow-Up
Census: 63
Deficiencies: 3
Aug 7, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to background checks, water temperature, and tuberculosis testing were corrected.
Deficiencies (3)
| Description |
|---|
| Failed to determine whether a prospective employee had the character, competence, and suitability to work with vulnerable adults due to incomplete background check review. |
| Failed to ensure hot water temperatures in sinks used by residents were between 105 and 120 degrees Fahrenheit, with measured temperatures outside this range. |
| Failed to complete tuberculosis testing within three days of hire for sampled staff, placing staff and residents at risk of exposure. |
Report Facts
Residents present during inspection: 63
Sampled residents: 7
Sampled staff: 5
Sampled staff for TB testing: 3
Hot water temperature measurements: 131
Hot water temperature measurements: 93.8
Hot water temperature measurements: 122.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Gehlen | ALF Licensor - LTC | Department staff who did the on-site verification |
| Jennifer Siharath | ALF Licensor | Department staff who did the on-site verification |
| Staff F | Caregiver | Subject of background check deficiency |
| Staff D | Medication Aide | Subject of tuberculosis testing deficiency |
| Staff E | Medication Aide | Subject of tuberculosis testing deficiency |
| Staff A | Executive Director | Acknowledged department findings and deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 6
May 16, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previous fire safety violations.
Findings
Several fire safety violations were noted as not corrected, including issues with fire-resistance-rated construction, fire door assemblies, duct and air transfer openings, smoke detector sensitivity, and portable heaters. Some violations were marked as complete or resolved with follow-up actions scheduled.
Deficiencies (6)
| Description |
|---|
| Annual inspection of fire resistance-rated construction not conducted |
| Multiple doors throughout building found with excessive gap |
| Fire doors shall accessories removed from doors such as wreaths |
| Facility failed to provide 4 year fire damper inspection report |
| Smoke detector sensitivity shall be checked within one year after installation of new device |
| Portable heaters compliance issues noted, some resolved |
Report Facts
Next inspection scheduled date: Jun 15, 2025
Next inspection scheduled date: Mar 22, 2025
Next inspection scheduled date: Feb 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Conducted the re-inspection and signed the report |
| Andrea Pineda | Executive Director | Facility representative signing and involved in follow-up actions |
Inspection Report
Re-Inspection
Deficiencies: 7
May 16, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited fire safety violations.
Findings
The re-inspection found that several fire safety violations had been corrected or were in the process of being corrected, including fire-resistance-rated construction, fire door maintenance, and portable heater compliance. Some items were noted as complete, while others were pending follow-up or awaiting inspection reports.
Deficiencies (7)
| Description |
|---|
| Owner shall maintain an inventory of all required fire-resistance-rated construction and inspect annually. |
| Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained according to NFPA standards. |
| Dampers protecting ducts and air transfer openings shall be inspected and maintained; facility failed to provide 4-year fire damper inspection report. |
| Portable heaters must comply with 2021 International Fire Code requirements. |
| Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. |
| Commercial cooking systems must have appropriate fire extinguishing systems installed and maintained. |
| Emergency and standby power systems shall be maintained to supply service within required timeframes. |
Report Facts
Next inspection scheduled date: Jun 15, 2025
Next inspection scheduled date: Mar 22, 2025
Next inspection scheduled date: Feb 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple pages |
| Andrea Rineda | Executive Director | Signed as Authorized Facility Representative on page 14 |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
May 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation due to allegations that the facility failed to make identified repairs as outlined by the fire marshal to be compliant with fire code.
Findings
The investigation found that the facility failed to stay in compliance with the Washington State Patrol Fire Protection Bureau for two consecutive inspections, placing residents, visitors, and staff at risk. Multiple fire code violations were identified, including issues with fire doors, fire damper inspections, and smoke detector sensitivity.
Complaint Details
The complaint was substantiated with failed provider practice identified and citations written related to fire safety violations.
Deficiencies (1)
| Description |
|---|
| Facility failed to make identified repairs as outlined by fire marshal to be compliant with fire code. |
Report Facts
Total residents: 69
Fire inspection violations: 10
Fire inspection violations: 5
Extension days approved: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Rose | Investigator | Conducted the complaint investigation |
| Clinton Fridley | Adult Family Home Nurse Field Manager | Signed follow-up inspection report and statement of deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 4
Feb 20, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited fire safety violations.
Findings
The re-inspection found that some violations related to fire-resistance-rated construction, fire door inspection, smoke detector sensitivity, and duct and air transfer openings had not yet been corrected, while portable heater violations were resolved.
Deficiencies (4)
| Description |
|---|
| Annual inspection of fire resistance-rated construction shall be conducted |
| Annual fire door inspection shall be conducted; multiple doors throughout building found with excessive gap; fire door shall accessories removed from doors such as wreaths |
| Facility failed to provide 4 year fire damper inspection report |
| Smoke detector sensitivity shall be checked within one year after installation of new device |
Report Facts
Next inspection scheduled on or after: Mar 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the re-inspection |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Sep 27, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations of an unclean physical environment and improper dietary services, including unsanitary kitchen conditions and improper food labeling and temperature monitoring.
Findings
The investigation found failed practices related to the physical environment, including an unsanitary kitchen and refrigerator, and dietary services, such as unlabeled and undated food items and inadequate food temperature monitoring. These deficiencies placed all 64 residents at risk of foodborne illness.
Complaint Details
Complaint investigation based on allegations of unsanitary physical environment and improper dietary services. Substantiated with failed provider practices and citations written.
Deficiencies (2)
| Description |
|---|
| Facility is not clean; kitchen cleaning procedures are not enforced and refrigerator is unsanitary. |
| Food is not properly labeled and food temperatures are not monitored for safety. |
Report Facts
Total residents: 64
Resident sample size: 3
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Rose | Investigator | Conducted the complaint investigation and on-site verification |
| Andrea Pineda | Executive Director | Named in relation to interviews and corrective actions regarding kitchen cleaning and food safety |
Loading inspection reports...



