Inspection Reports for The Gardens at Town Square
933 111th Ave NE, Bellevue, WA 98004, United States, WA, 98004
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Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Apr 25, 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 and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Report Facts
Residents present during follow-up visit: 38
Residents at risk: 60
Total residents: 60
Resident sample size: 1
Days after hire Staff A completed training: 197
Days after hire Staff A scheduled State Skills Competency Exam: 287
Days after hire Staff A worked without certification: 272
Medication administration days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Yip | ALF Licensor | Department staff who conducted the follow-up inspection and complaint investigation |
| Laurie Anderson | Community Field Manager | Signed follow-up inspection letter and Statement of Deficiencies |
| Staff A | Resident Assistant, NAR | Named staff who failed to complete required nursing assistant certification within required timeframe and worked unqualified, administering medications |
| Staff B | Executive Director | Interviewed regarding awareness of certification requirements and Staff A's status |
Inspection Report
Life Safety
Deficiencies: 10
Apr 23, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the residential care facility Gardens At Town Square on 04/23/2025.
Findings
Multiple fire safety deficiencies were cited including inadequate ceiling clearance, use of extension cords for permanent wiring, disabled smoke detectors, missing inspection paperwork, unsecured compressed gas cylinders, and fire alarm equipment issues.
Deficiencies (10)
| Description |
|---|
| Floor 2 linen room had only 18 inches of clearance around sprinkler head, less than required 2 feet. |
| Extension cord spliced into lighting fixture in ceiling for permanent wiring. |
| Open electrical junction box in memory care kitchen pantry. |
| Extension cords used for permanent wiring in Activities office, beneath front desk, and in azalea room. |
| Facility lacked required detailed documentation and maps of fire-rated construction locations and inspection reports. |
| Both smoke detectors in room #283 were disabled with tape impeding detection. |
| Annual Sprinkler System Report was not provided. |
| Second semi-annual service paperwork for extinguishing system was not provided. |
| Fire alarm breaker did not have locking device installed. |
| Unsecured compressed gas cylinders in kitchen storage room #129. |
Report Facts
Next inspection scheduled date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Sarah Betz | Executive Director | Facility Owner's Representative who signed the report |
Inspection Report
Enforcement
Census: 38
Deficiencies: 1
Feb 26, 2025
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to impose a civil fine based on previously cited deficiencies related to staff qualifications at the assisted living facility.
Findings
The licensee failed to ensure that one staff member was qualified to work with vulnerable adult residents, placing all 38 residents at risk. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that one staff was qualified to work with vulnerable adult residents. |
Report Facts
Civil fine amount: 300
Residents at risk: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Laurie Anderson | Field Manager | Contact person for the plan of correction and follow-up. |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 31, 2024
Visit Reason
The document reports the results of an Informal Dispute Resolution (IDR) process addressing a dispute related to a Statement of Deficiencies (SOD) report dated October 31, 2024, for an Assisted Living Facility.
Findings
After review of materials, oral statements, and records, a change was made to the SOD by deleting WAC 388-78A-2700.
Deficiencies (1)
| Description |
|---|
| WAC 388-78A-2700 - Deleted |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Signed the IDR results letter |
Inspection Report
Life Safety
Deficiencies: 1
Jun 4, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 06/04/2024.
Findings
The inspection found that all previously noted violations had been corrected except for one deficiency related to the periodic inspection and testing of NFPA 80 Fire/Smoke Dampers, where paperwork showing unresolved deficiencies was not provided.
Deficiencies (1)
| Description |
|---|
| At the time of inspection, paperwork was not provided showing that deficiencies related to NFPA 80 Fire/Smoke Dampers inspection and testing had been resolved. |
Report Facts
Next inspection scheduled: Jul 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Esayas Solomon | Environmental Services Director | Owner's Representative who signed the report |
Inspection Report
Annual Inspection
Deficiencies: 0
May 1, 2023
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 05/01/2023 as part of a compliance determination.
Findings
The inspection found no deficiencies in the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Garrett | LTC Licensor | Department staff who did the inspection |
| Claudia Machado | Community Complaint Investigator | Department staff who did the inspection |
Inspection Report
Life Safety
Deficiencies: 17
Apr 20, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire protection codes and regulations.
Findings
The inspection found multiple violations including blocked electrical panel access, missing documentation for required tests and inspections, fire doors failing to latch, missing smoke detectors, missing fire drill documentation, and missing fire alarm circuit breaker lock. The facility was disapproved due to these deficiencies.
Deficiencies (17)
| Description |
|---|
| Combustible storage found blocking access to the electrical panel in the life enrichment supply room. |
| Power strip plugged into another power strip in the copy room on the ground floor. |
| Facility unable to provide documentation for the semi-annual hood cleaning report. |
| Facility shall provide an inventory of all fire-resistance-rated construction in the building; multiple unprotected penetrations found throughout the building with no plans to identify wall ratings. |
| Facility unable to provide documentation showing annual fire door inspection completed in past 12 months. |
| Fire door to memory care kitchen storage failed to latch when tested. |
| Fire door not latching in main kitchen next to bussing station. |
| Air flow vent in fourth floor residents laundry room's fire-resistance-rated corridor wall missing required fire/smoke damper control system. |
| Multiple loaded sprinkler heads observed in the kitchen. |
| Unprotected gap around sprinkler escutcheon ring next to Apt. 532. |
| Facility unable to provide documentation that annual fire extinguishers inspection has been completed. |
| Life enrichment storage room missing smoke detector; device removed with no cover over wiring. |
| Multiple pull stations missing replacement glass rods on all floors. |
| Facility unable to provide documentation for monthly check of all carbon monoxide detectors. |
| Facility unable to provide records of monthly 30-minute full load testing of emergency and standby power systems in past 12 months. |
| Fire alarm circuit breaker in main electrical room missing required lock device, locking breaker in 'ON' position. |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months; multiple shifts and quarters missing drills. |
Report Facts
Missing fire drills: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on the inspection report |
Inspection Report
Re-Inspection
Deficiencies: 5
Apr 12, 2022
Visit Reason
The inspection was a re-inspection conducted to verify correction of previously cited deficiencies related to fire safety and emergency systems at the facility.
Findings
The facility failed to correct multiple deficiencies cited on 2022-03-07, including overdue annual inspection and testing of the emergency generator, failure to maintain fire-rated doors that close and latch properly, outdated dry sprinkler heads in the walk-in cooler and freezer, and failure to maintain records of confidence tests and fire drills.
Deficiencies (5)
| Description |
|---|
| The annual inspection and testing of the emergency generator is past due; no records of monthly load tests or weekly inspections for the generator were maintained. |
| The door to the memory care activity room across from resident room 264 failed to close and latch. |
| The dry sprinkler heads in the walk-in cooler and freezer appear to be more than ten years old and shall be tested or replaced. |
| Failure to maintain records of confidence tests for the sprinkler system and fire alarm panel. |
| Failure to maintain records of quarterly fire drills. |
Report Facts
Next inspection scheduled date: May 12, 2022
Next inspection scheduled date: Apr 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don West | Deputy State Fire Marshal | Named as Deputy State Fire Marshal conducting the inspection and signing the report. |
| Cozetta Christian | Deputy State Fire Marshal | Named as Deputy State Fire Marshal conducting the inspection and signing the report. |
Notice
Deficiencies: 0
The Gardens at Town Square 1604 49111 103124 IDR Sch Ltr
Visit Reason
The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility administrator to dispute a citation from the Statement of Deficiencies dated October 31, 2024.
Findings
The document does not contain inspection findings but focuses on scheduling the IDR meeting and identifying the citation being disputed (WAC 388-78A-2700).
Report Facts
Citation date: Oct 31, 2024
IDR meeting date: Dec 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Betz | Administrator | Facility representative participating in the IDR process |
| Karen Nordby | Regional Director of Operations | Facility representative participating in the IDR process |
| Sarah Chimbanga | Director of Health and Wellness | Facility representative participating in the IDR process |
| Kim Friesz | Administrative Assistant 3 | Sender of the scheduling letter |
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