Inspection Reports for The Inn at University Village Assisted Living Community
2723 NE 134th St, Vancouver, WA 98686, United States, WA, 98686
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Inspection Report
Life Safety
Deficiencies: 9
Aug 29, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to evaluate compliance with fire safety codes and maintenance requirements.
Findings
The inspection identified multiple violations including failure to provide annual inspection of fire resistance rated construction and inventory, failure to provide documentation of fire damper testing, failure to provide quarterly fire sprinkler inspection reports, missing fire sprinkler protection in stairwells, and deficiencies in portable fire extinguisher maintenance and placement.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide annual inspection of fire resistance rated construction and inventory |
| Fire dampers shall have inspection complete 1 year after installation. Facility fails to provide documentation of testing. |
| Facility failed to provide quarterly fire sprinkler inspection report |
| Fire sprinkler riser found to have gauge greater than 5 years old |
| Fire sprinkler coverage shall be correct in stairwells. Missing fire sprinkler protection |
| Facility failed to provide semi annual hood suppression system inspection |
| Fire extinguisher in kitchen found blocked by cart |
| Class ABC fire extinguisher found missing in kitchen |
| Facility failed to provide fire drill for swing shift fourth quarter of 2024 |
Report Facts
Fire drills required: 12
Fire sprinkler gauge age: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Jones | Executive Director | Signed as Owner or Authorized Representative |
| Nicholas Wolden | Deputy State Fire Marshal | Signed as inspecting official |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 28, 2025
Visit Reason
The document reports on the Informal Dispute Resolution (IDR) process held on August 28, 2025, addressing a citation from the Statement of Deficiencies (SOD) report dated August 5, 2025.
Findings
After review, the citation from the SOD dated August 5, 2025 was deleted, resulting in the deletion of the entire SOD report.
Deficiencies (1)
| Description |
|---|
| Citation under WAC 388-78A-2610 |
Report Facts
License number: 2668
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staci Dilg | IDR Program Manager | Author of the IDR results letter |
Inspection Report
Life Safety
Deficiencies: 10
Jul 1, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at The Inn at University Village to assess compliance with fire safety codes and maintenance requirements.
Findings
The facility was found to have multiple deficiencies including failure to provide required fire inspection reports, incomplete fire sprinkler protection, missing fire extinguisher equipment, failure to maintain fire resistance rated construction and inventory, and inadequate fire drill documentation and scheduling.
Deficiencies (10)
| Description |
|---|
| Facility failed to provide annual fire door inspection report |
| Fire dampers shall have inspection complete 1 year after installation. Facility fails to provide documentation of testing. Repairs fail to be completed and documented |
| Fire sprinkler coverage shall be correct in stairwells. Missing fire sprinkler protection |
| Facility failed to provide quarterly fire sprinkler inspection report. Fire sprinkler riser found to have gauge greater than 5 years old |
| Facility failed to provide annual inspection of fire resistance rated construction and inventory |
| Mechanical room near room 222 found to have hole in fire rated ceiling |
| Facility failed to provide hood system cleaning as required |
| Facility failed to provide semi annual hood suppression system inspection |
| Fire extinguisher in kitchen found blocked by cart. Class ABC fire extinguisher found missing in kitchen |
| Facility failed to provide fire drill for swing shift fourth quarter of 2024 |
Report Facts
Next inspection scheduled date: Next inspection scheduled on or after 11/02/2025 (page 3)
Next inspection scheduled date: Next inspection scheduled on or after 09/28/2025 (page 8)
Next inspection scheduled date: Next inspection scheduled on or after 08/01/2025 (page 13)
Fire sprinkler riser gauge age: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Jones | Executive Director | Signed as Owner or Authorized Representative on multiple pages |
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple pages |
Inspection Report
Re-Inspection
Deficiencies: 8
Jul 31, 2024
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
The facility was found to have multiple fire safety violations including failure to conduct annual fire extinguisher inspections, excessive grease accumulation in hood systems, fire doors not meeting NFPA 80 requirements, failure to close and latch fire doors properly, failure to provide quarterly fire sprinkler inspections, failure to service automatic fire-extinguishing systems semi-annually, failure to provide documentation of monthly emergency lighting tests, and failure to provide any fire drills for 2023.
Deficiencies (8)
| Description |
|---|
| Facility failed to conduct annual fire extinguisher inspections |
| Excessive accumulation of grease found in hood system-cleaning shall be conducted |
| Fire doors failed to meet NFPA 80 requirements including gaps and wedged open doors |
| Door failed to close and latch properly in Laundry room |
| Facility failed to provide quarterly fire sprinkler inspections |
| Facility failed to provide semi-annual hood suppression system inspection |
| Facility failed to provide documentation of monthly emergency lighting |
| Facility failed to provide any fire drills for 2023 |
Report Facts
Next inspection scheduled: Aug 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on the inspection report |
Inspection Report
Re-Inspection
Deficiencies: 8
Jul 31, 2024
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previous violations.
Findings
The facility was found to have multiple fire safety violations that had not been corrected, including failure to conduct annual fire extinguisher inspections, excessive grease accumulation in the hood system, fire doors not meeting NFPA 80 requirements, doors failing to close and latch properly, failure to provide quarterly fire sprinkler inspections, and failure to provide documentation of monthly emergency lighting.
Deficiencies (8)
| Description |
|---|
| Facility failed to conduct annual fire extinguisher inspections |
| Excessive accumulation of grease found in hood system-cleaning shall be conducted |
| Fire doors failed to meet NFPA 80 requirements including gaps and wedged open doors |
| Door failed to close and latch properly in laundry room |
| Facility failed to provide quarterly fire sprinkler inspections |
| Facility failed to provide quarterly fire sprinkler inspections (Extinguishing System Service) |
| Facility failed to conduct annual fire extinguisher inspections (Portable Fire Extinguishers) |
| Facility failed to provide documentation of monthly emergency lighting |
Report Facts
Next inspection scheduled on or after: Aug 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
| Erin Jones | Executive Director | Facility representative signing the inspection report |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Jun 21, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 06/21/2024 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. The prior deficiencies cited in the May 2024 inspection were corrected.
Report Facts
Residents reviewed during unannounced on-site visit: 10
Current residents census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Gehlen | ALF Licensor - LTC | Department staff who did the off-site verification |
| Jennifer Siharath | ALF Licensor | Department staff who did the off-site verification and inspected the facility |
| Michael Burdick | Field Manager | Signed the follow-up inspection letter |
Notice
Deficiencies: 0
The Inn at University Village Salmon Creek 2668 62751 080525 IDR Sch Ltr
Visit Reason
The document confirms the facility's request for an Informal Dispute Resolution (IDR) regarding a Statement of Deficiencies dated August 5, 2025, and schedules a virtual meeting for August 28, 2025.
Findings
The letter does not contain inspection findings but indicates that the facility is disputing citation WAC 388-78A-2610 and requests additional documentation related to the citation.
Report Facts
Citation date: Aug 5, 2025
Scheduled IDR date: Aug 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Jones | Executive Director | Participant representing the facility in the IDR process |
| Cyndi Pollard | Senior Executive Director | Participant representing the facility in the IDR process |
| Rena Sicard | Director of Resident Services | Participant representing the facility in the IDR process |
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