The most recent inspection on August 25, 2025, resulted in enforcement action with a $2,000 fine that was fully paid. Prior inspections showed repeated deficiencies related to caregiver skills verification, staff training, service plans, fall prevention, medication management, and documentation, with multiple enforcement actions including fines in 2023 and 2025. Complaint investigations found numerous issues in personnel records, service plans, and policies, but no substantiated complaints were noted after February 2023. Enforcement actions focused mainly on staff training, verification of caregiver skills, and compliance with safety and documentation standards. The facility’s record shows ongoing challenges with these areas despite corrective efforts, with repeated citations and fines indicating persistent issues over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found to have multiple repeat deficiencies from a prior inspection on February 7, 2023, including failure to ensure caregiver skills, proper documentation, and training programs, resulting in civil fines.
Fines & Penalties (1)
Amount
Reason
Status
$2,000.00
Civil fines for multiple violations including failure to ensure caregiver skills, orientation, documentation, resident service plans, and staff training.
Fourteen deficiencies identified related to fall prevention training, tuberculosis screening, opioid prescribing, administration compliance, personnel verification, service plans, medication services, emergency and safety standards, and environmental standards. Ola Ojasope was responsible for corrective actions.
Findings
Fourteen deficiencies identified related to fall prevention training, tuberculosis screening, opioid prescribing, administration compliance, personnel verification, service plans, medication services, emergency and safety standards, and environmental standards. Ola Ojasope was responsible for corrective actions.
Deficiencies (14)
Description
A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition
R9-10-113.A.1-2. Tuberculosis Screening
R9-10-120.F.4.a-c. Opioid Prescribing and Treatment
The facility was found non-compliant for not having CPR demonstration documentation and failing to verify caregiver skills and knowledge, resulting in civil fines.
Fines & Penalties (2)
Amount
Reason
Status
$500.00
Failure to implement policies and procedures to protect resident health and safety related to CPR training and demonstration.
—
$250.00
Failure to ensure caregiver skills and knowledge were verified and documented before providing physical health services.
Nineteen deficiencies identified during complaint investigation including failures in personnel records, service plans, documentation, policies and procedures, and food menu posting. Complaint #AZ00189008 was investigated.
Findings
Nineteen deficiencies identified during complaint investigation including failures in personnel records, service plans, documentation, policies and procedures, and food menu posting. Complaint #AZ00189008 was investigated.
Complaint Details
Complaint #AZ00189008 investigated during the February 7, 2023 inspection
Deficiencies (19)
Description
A.R.S. § 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: a. At least 21 years of age, and b. Present on the premises
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident
E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request
A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health care or assistance
A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistants
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: b. The individual's starting date of employment or volunteer service
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: ii. The individual's education and training
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: iii. The individual's completed orientation
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when revised, is signed and dated by the resident or resident's representative
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when revised, is signed and dated by the manager
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record
C. A manager shall ensure that a resident's medical record contains: 4. The date of acceptance and, if applicable, date of termination of residency
C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumococcal disease
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided
A. A manager shall ensure that: 1. A food menu: c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served
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