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
NameTitleContext
Erin JonesExecutive DirectorSigned as Owner or Authorized Representative
Nicholas WoldenDeputy State Fire MarshalSigned 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
NameTitleContext
Staci DilgIDR Program ManagerAuthor 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
NameTitleContext
Erin JonesExecutive DirectorSigned as Owner or Authorized Representative on multiple pages
Nicholas D. WoldenDeputy State Fire MarshalSigned 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
NameTitleContext
Nicholas WoldenDeputy State Fire MarshalSigned 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
NameTitleContext
Nicholas D. WoldenDeputy State Fire MarshalSigned as Deputy State Fire Marshal conducting the inspection
Erin JonesExecutive DirectorFacility 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
NameTitleContext
Kyle GehlenALF Licensor - LTCDepartment staff who did the off-site verification
Jennifer SiharathALF LicensorDepartment staff who did the off-site verification and inspected the facility
Michael BurdickField ManagerSigned 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
NameTitleContext
Erin JonesExecutive DirectorParticipant representing the facility in the IDR process
Cyndi PollardSenior Executive DirectorParticipant representing the facility in the IDR process
Rena SicardDirector of Resident ServicesParticipant representing the facility in the IDR process

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