Inspection Reports for Paradise Valley Senior Living

16621 N 38th St, Phoenix, AZ 85032, United States, AZ, 85032

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Inspection Report Summary

The most recent inspection on August 9, 2025, included enforcement action resulting in a $2,250 fine that has been paid in full. Earlier inspections showed a pattern of deficiencies related primarily to medication administration, environmental standards, personnel documentation, service plan completion and updates, emergency drills, and safe storage of toxic materials. Complaint investigations generally found deficiencies in medication services, documentation, and fall prevention training, while most complaints were unsubstantiated. Enforcement actions with fines have been frequent, reflecting ongoing compliance challenges, but all fines have been paid in full as noted in the reports. The facility’s inspection history shows recurring issues with medication management and administrative compliance, with no clear trend of improvement or worsening over time.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 19 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

414% worse than Arizona average
Arizona average: 3.7 deficiencies/year

Deficiencies per year

16 12 8 4 0
2023
2024
2025
Enforcement Action Enforcement Fines: 1 Total: $2,250.00 Aug 9, 2025
Summary
The facility was fined $2,250.00, which has been paid in full as of the completion date.
Fines & Penalties (1)
AmountReasonStatus
$2,250.00Financial penalty related to enforcement actionPaid
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 2 Jun 16, 2025
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Two deficiencies found related to medication services and environmental standards during complaint investigation.
Findings
Two deficiencies found related to medication services and environmental standards during complaint investigation.
Deficiencies (2)
Description
R9-10-816.B.3.b. Medication Services — Medication administration compliance issues
R9-10-819.A.13.a-c. Environmental Standards — Equipment maintenance failures
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 0 Jun 3, 2025
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Enforcement Action Enforcement Fines: 1 Total: $750.00 May 15, 2025
Summary
The facility was fined $750.00, which has been paid in full as of the due date.
Fines & Penalties (1)
AmountReasonStatus
$750.00Fine associated with enforcement action #00122466Paid
Enforcement Action Enforcement Fines: 5 Total: $2,250.00 Apr 30, 2025
Summary
The facility was found to have multiple repeat deficiencies from prior inspections and a complaint, resulting in civil fines totaling $2,250.00.
Fines & Penalties (5)
AmountReasonStatus
$500.00One employee permitted to work after fingerprint clearance card expired; repeat deficiency from May 8, 2024 compliance inspection.
$500.00One employee's first aid and cardiopulmonary resuscitation (CPR) training expired.
$500.00No evacuation drills conducted within the last 12 months; repeat deficiency from May 8, 2024 compliance inspection.
$250.00Documentation of a current fire inspection was not available for review during the inspection; repeat deficiency from May 8, 2024 compliance inspection.
$500.00Facility did not store poisonous or toxic materials in a locked area and inaccessible to residents; repeat deficiency from complaint inspection December 18, 2023 and compliance inspection May 8, 2024.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 15 Apr 30, 2025
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Fifteen deficiencies found during compliance inspection and complaint investigation covering tuberculosis screening, opioid prescribing, administration, personnel, service plans, medication storage, emergency standards, and environmental standards.
Findings
Fifteen deficiencies found during compliance inspection and complaint investigation covering tuberculosis screening, opioid prescribing, administration, personnel, service plans, medication storage, emergency standards, and environmental standards.
Deficiencies (15)
Description
R9-10-113.A.2.a-f. Tuberculosis Screening — Failure to document and implement TB screening
R9-10-120.F.4.a-c. Opioid Prescribing and Treatment — Inadequate opioid medication documentation
R9-10-803.A.9. Administration — Personnel records incomplete
R9-10-803.C.3. Administration — Policies and procedures not reviewed or updated timely
R9-10-803.D.1-4. Administration — Inspection report posting failures
R9-10-806.A.10. Personnel — Lack of current first aid and CPR documentation
R9-10-806.A.8.a-b. Personnel — Failure to document freedom from infectious tuberculosis
R9-10-807.A.1-2. Residency and Residency Agreements — Failure to provide evidence of freedom from infectious tuberculosis
R9-10-808.A.3.c. Service Plans — Incomplete or missing written service plans
R9-10-816.B.3.a-c. Medication Services — Medication administration documentation failures
R9-10-816.F.1. Medication Services — Medication storage not secure
R9-10-818.A.5.a. Emergency and Safety Standards — Evacuation drills not conducted biannually
R9-10-818.E.5. Emergency and Safety Standards — Fire inspection documentation missing
R9-10-819.A.11. Environmental Standards — Poisonous or toxic materials improperly stored
R9-10-819.A.2. Environmental Standards — Pest control program noncompliance
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 2 Dec 20, 2024
Visit Reason
Two deficiencies cited related to fall prevention training and documentation of caregiver actions after resident incidents.
Findings
Two deficiencies cited related to fall prevention training and documentation of caregiver actions after resident incidents.
Deficiencies (2)
Description
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — Failure to develop and administer fall prevention training
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
Inspection Report Capacity: 118 Deficiencies: 0 Dec 17, 2024
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No deficiencies found during off-site modification for a name change.
Findings
No deficiencies found during off-site modification for a name change.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 0 Sep 27, 2024
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No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 0 Sep 12, 2024
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No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 1 Sep 9, 2024
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One deficiency cited related to failure to document witness names after suspected abuse.
Findings
One deficiency cited related to failure to document witness names after suspected abuse.
Deficiencies (1)
Description
J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred — Failure to document witness names
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 1 Aug 23, 2024
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One deficiency cited related to failure to document abuse or neglect when manager had reasonable basis to believe it occurred.
Findings
One deficiency cited related to failure to document abuse or neglect when manager had reasonable basis to believe it occurred.
Deficiencies (1)
Description
J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred — Failure to document abuse or neglect
Enforcement Action Enforcement Fines: 7 Total: $7,540.00 Jul 31, 2024
Summary
The enforcement resulted in multiple fines totaling $7,540.00 for repeated and new violations found during the compliance and complaint inspection conducted on May 8, 2024, including repeat citations from previous inspections.
Fines & Penalties (7)
AmountReasonStatus
$1,000.00Failure to ensure compliance with fingerprint clearance cards for two employees.
$500.00Failure to ensure two assistant caregivers interacted with residents only under supervision.
$500.00Failure to verify skills and knowledge of three assistant caregivers before providing physical health services (repeat citation).
$4,290.00Failure to ensure a service plan was completed for one resident (triple-repeat citation) with daily penalties assessed for 143 days.
$500.00Failure to update service plans for two residents at least every three months (double-repeat citation).
$500.00Failure to conduct and document evacuation drills at least once every six months.
$250.00Failure to store poisonous or toxic materials in a locked area inaccessible to residents (repeat citation).
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 0 Jul 2, 2024
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Enforcement Action Enforcement Fines: 1 Total: $7,540.00 Jun 25, 2024
Summary
A fine of $7,540.00 was imposed and has been paid in full as of the completion date.
Fines & Penalties (1)
AmountReasonStatus
$7,540.00Financial penalty related to enforcement actionPaid
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 10 May 8, 2024
Visit Reason
Ten deficiencies cited during compliance inspection and complaint investigation related to personnel compliance, service plans, emergency drills, fire inspections, poisonous materials, opioid prescribing, and food service.
Findings
Ten deficiencies cited during compliance inspection and complaint investigation related to personnel compliance, service plans, emergency drills, fire inspections, poisonous materials, opioid prescribing, and food service.
Deficiencies (10)
Description
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 — Failure to ensure compliance with statute for employees
A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under supervision — Failure to ensure supervision
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented — Failure to verify caregiver skills
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 mo... — Failure to document freedom from infectious tuberculosis
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 cale... — Failure to complete service plans timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; — Failure to conduct disaster drills quarterly
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and — Failure to conduct evacuation drills biannually
E. A manager of an assisted living center shall ensure that: 3. A fire inspection is conducted by a local fire department or the State Fire Marshal be... — Failure to conduct fire inspections timely
A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a lock... — Failure to store poisonous materials securely
Enforcement Action Enforcement Fines: 1 Total: $1,000.00 Jan 2, 2024
Summary
The enforcement action resulted in a $1,000 fine which has been paid in full.
Fines & Penalties (1)
AmountReasonStatus
$1,000.00Fine related to enforcement action against the facilityPaid
Enforcement Action Enforcement Fines: 1 Total: $500.00 Oct 31, 2023
Summary
A fine of $500.00 was imposed and has been paid in full as part of the enforcement action.
Fines & Penalties (1)
AmountReasonStatus
$500.00Fine imposed as part of enforcement actionPaid
Enforcement Action Enforcement Fines: 2 Total: $500.00 Oct 10, 2023
Summary
The facility was found to have no documented verification of skills and knowledge for two employees and a repeat citation for failure to notify emergency contacts promptly, resulting in civil fines.
Fines & Penalties (2)
AmountReasonStatus
$250.00Failure to ensure the skills and knowledge of two employees were verified and documented before providing physical health services.
$250.00Failure to ensure a resident's emergency contact and primary care provider were immediately notified after an accident; repeat citation.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 5 Oct 10, 2023
Visit Reason
Five deficiencies cited related to fall prevention training, caregiver skills verification, diet provision, and documentation of medical services after incidents.
Findings
Five deficiencies cited related to fall prevention training, caregiver skills verification, diet provision, and documentation of medical services after incidents.
Deficiencies (5)
Description
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — Failure to develop and administer fall prevention training
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented — Failure to verify caregiver skills
A. A manager shall ensure that: 6. A resident is provided a diet that meets the resident's nutritional needs as specified in the resident's service pl... — Failure to provide appropriate diet
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
Enforcement Action Enforcement Fines: 1 Total: $1,500.00 Aug 11, 2023
Summary
The facility was found deficient in multiple areas including CPR policy and training documentation, resident care documentation, medication administration records, and safety measures for resident egress. These deficiencies posed risks to resident health and safety and resulted in repeat violations.
Fines & Penalties (1)
AmountReasonStatus
$1,500.00Civil fines for multiple violations including failure to establish CPR policies, inadequate documentation of CPR training, failure to ensure proper resident care documentation, and repeat deficiencies related to resident safety and medication administration.
Enforcement Action Enforcement Fines: 1 Total: $1,500.00 Jul 25, 2023
Summary
A fine of $1,500.00 was imposed and has been paid in full as part of the enforcement action.
Fines & Penalties (1)
AmountReasonStatus
$1,500.00Fine imposed as part of enforcement actionPaid
Enforcement Action Enforcement Fines: 2 Total: $1,000.00 Jul 14, 2023
Summary
The facility failed to ensure timely completion of written service plans for residents and failed to prevent residents from being subjected to restraint, posing risks of physical injury or psychological distress. The Department was unable to determine substantial compliance during the inspection.
Fines & Penalties (2)
AmountReasonStatus
$500.00Failure to complete a resident's written service plan within 14 calendar days.
$500.00Failure to ensure residents were not subjected to restraint, posing potential physical injury or psychological distress.
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 11 Jul 3, 2023
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Eleven deficiencies cited related to policies and procedures, personnel documentation, service plans, documentation of services, restraint, medication orders, and hot water temperature.
Findings
Eleven deficiencies cited related to policies and procedures, personnel documentation, service plans, documentation of services, restraint, medication orders, and hot water temperature.
Deficiencies (11)
Description
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident — Failure to establish and implement policies
A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of ... — Failure to provide current first aid and CPR documentation
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: iii. The individual's completed or... — Personnel records incomplete
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and — Failure to document services provided
B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint — Failure to prevent resident restraint
C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is ad... — Medication orders missing
B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is a... — Medication administration compliance issues
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re... — Hot water temperature not maintained
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
Enforcement Action Enforcement Fines: 1 Total: $1,000.00 Jun 27, 2023
Summary
The facility was fined $1,000.00 which has been paid in full as of 7/24/2023.
Fines & Penalties (1)
AmountReasonStatus
$1,000.00Fine related to enforcement actionPaid
Inspection Report Complaint Investigation Capacity: 118 Deficiencies: 10 Jun 5, 2023
Visit Reason
Ten deficiencies cited related to notification to Department, policies and procedures, documentation, service plans, restraint, medical records, and poisonous materials.
Findings
Ten deficiencies cited related to notification to Department, policies and procedures, documentation, service plans, restraint, medical records, and poisonous materials.
Deficiencies (10)
Description
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 cha... — Failure to notify Department of manager change
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident... — Failure to implement policies and procedures
E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours afte... — Failure to provide documentation timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 cale... — Failure to complete service plans timely
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and — Failure to document services provided
B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint — Failure to prevent resident restraint
C. A manager shall ensure that a resident's medical record contains: 10. Resident's service plan and updates; — Service plan and updates missing
C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is ad... — Medication orders missing
B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is a... — Medication administration compliance issues
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re... — Hot water temperature not maintained

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