Inspection Reports for The Lakeshore
11448 Rainier Ave S, Seattle, WA 98178, USA, WA, 98178
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Inspection Report
Life Safety
Deficiencies: 6
Feb 26, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire safety codes and regulations.
Findings
The facility was found to have multiple violations related to fire and life safety, including failure to provide annual inspection reports for the sprinkler system, fire alarm system, smoke detector sensitivity tests, and generator; failure to maintain fire door double doors; and issues with damper protection and fire door hardware.
Deficiencies (6)
| Description |
|---|
| Some dampers failed and corrections were needed. |
| Facility failed to provide annual inspection report for the automatic sprinkler system. |
| Facility failed to provide annual inspection report for the automatic fire alarm system. |
| Facility failed to provide smoke detectors sensitivity test. |
| Facility failed to provide annual inspection report for the generator. |
| Facility failed to maintain double doors #3V, failed to latch. |
Report Facts
Next inspection scheduled: Apr 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Freve | Executive Director | Named as Owner or Authorized Representative signing the inspection report |
| Raul Murcia | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Follow-Up
Census: 43
Deficiencies: 3
Sep 5, 2024
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 on 09/05/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to medication services and family assistance with medications were corrected.
Deficiencies (3)
| Description |
|---|
| Failed to implement systems to promote safe medication services for a resident, resulting in medication error and risk to health. |
| Failed to ensure a written family assistance plan, including a backup plan, for medication and treatment assistance for sampled residents. |
| Failed to secure toxic chemicals accessible to residents, placing five residents with cognitive impairment at risk of ingestion of a toxic substance. |
Report Facts
Residents sampled: 10
Residents at risk: 5
Residents without family assistance plan: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Singer | Field Manager | Signed letters and correspondence related to inspection and follow-up |
| Alma Duran | Licensor | Department staff who did on-site verification and inspection |
| Keiko Kitano | Licensor | Department staff who did on-site verification and inspection |
| Staff A | Community Health Director | Acknowledged medication error and lack of backup plans during interviews |
| Staff G | Personal Services Manager | Acknowledged medication error and lack of backup plans during interviews |
| Staff M | Regional Director of Health and Wellness/Registered Nurse | Interviewed regarding family assistance plans and medication management |
| Staff I | Medication Technician | Interviewed regarding unawareness of discontinued medication |
Inspection Report
Follow-Up
Census: 41
Deficiencies: 0
Mar 27, 2023
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 related to background checks were corrected.
Report Facts
Residents present during inspection: 41
Sample size for review: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who conducted the off-site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection report and compliance determination |
| Faith Le | NCI | Department staff who inspected the Assisted Living Facility during the on-site visit |
Inspection Report
Life Safety
Deficiencies: 20
Mar 7, 2023
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted at Lakeshore by a representative of the Washington State Patrol, State Fire Marshal's Office to determine compliance with all applicable codes.
Findings
Multiple fire and life safety code violations were observed, including unmaintained electrical panels, unapproved multiplug adapters, openings in ceilings, lack of documentation for hood cleaning and fire wall inspections, open conduits, fire doors not closing properly, outdated fire extinguishers, unsecured fire alarm breaker, overdue smoke detector sensitivity testing, missing documentation for CO detector testing, emergency lighting testing, power test, generator inspections, fire door labeling, and fire drill documentation.
Deficiencies (20)
| Description |
|---|
| Electrical panel in the 3rd floor storage room has not been maintained. |
| Unapproved multiplug adapters in tool room by 201 and office in the kitchen - 1st floor. |
| Opening in ceiling of Coffee room where a smoke detector was removed - 2nd floor. |
| Facility unable to provide documentation for annual and semi-annual hood cleaning. |
| Facility unable to provide record of annual fire wall inspection and/or repairs. |
| Open conduits in Trash / Recycle room - 2nd floor. |
| Facility unable to provide inventory record of annual inspection and/or repairs for all fire-resistant-rated doors. |
| Several fire doors did not close or latch properly when tested (multiple locations listed). |
| Facility's last damper testing (2019) shows they are overdue for next fire/smoke damper testing. |
| Facility's annual sprinkler report states multiple deficiencies. |
| Facility needs heat survey for commercial hood fusible link rating; currently five 450 degree links in place. |
| Out of date fire extinguishers in Wellness room back door and Generator area outside. |
| Fire alarm breaker not securely locked out in electrical panel in Fire Alarm panel room - ground floor. |
| Smoke detector sensitivity test overdue; scheduled for June 7. |
| Facility unable to provide documentation of CO detector testing in past 12 months. |
| Facility failed to provide documentation of 30-second monthly emergency lighting testing in last 12 months. |
| Facility failed to have annual 90 minute power test documentation readily available at inspection. |
| Facility has not conducted/documented required weekly/visual inspections of generator for last 12 months. |
| Facility failed to label, identify, and inventory their fire doors. |
| Facility unable to provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months. |
Report Facts
Number of 450 degree fusible links: 5
Year of last damper testing: 2019
Scheduled smoke detector sensitivity test date: Scheduled for June 7 (year not specified).
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mario Valdez | Facilities Director | Named as Owner or Authorized Representative signing the inspection report. |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
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