Inspection Report
Follow-Up
Deficiencies: 4
Aug 11, 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. The prior deficiencies cited in the full inspection conducted on 06/10/2025 and 06/12/2025 were corrected.
Deficiencies (4)
| Description |
|---|
| Failed to update 2 of 5 sampled residents' service plans, placing residents at risk for unmet care needs and diminished quality of life. |
| Failed to ensure 1 of 6 staff completed a national fingerprint background check, placing residents at risk of potential abuse or neglect. |
| Failed to ensure 1 of 6 staff completed all required training, including specialty training for dementia and mental health, placing residents at risk of unmet care needs. |
| Failed to ensure 1 of 6 staff completed the second step of a two-step tuberculosis skin test, placing residents at risk of exposure to TB. |
Report Facts
Residents reviewed: 5
Total residents: 23
Staff total: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Caregiver/Certified Nurse Assistant (CNA) | Failed to complete national fingerprint background check and required specialty training. |
| Staff D | Housekeeper | Failed to complete second step of two-step tuberculosis skin test. |
| Staff B | Licensed Practical Nurse, Assisted Living/Memory Care Manager | Interviewed regarding missing documentation in Resident 1 and Resident 2 service plans. |
| Staff A | Associate Executive Director/Administrator | Interviewed regarding awareness of fingerprint background check, specialty training, and TB screening requirements. |
Inspection Report
Life Safety
Deficiencies: 4
Jan 27, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the facility to assess compliance with fire protection and safety codes.
Findings
The inspection found violations including improper use of extension cords, missing annual fire extinguishers in the pantry and kitchen, and lack of required documentation for fire-resistance-rated construction inspections. The facility was disapproved due to these deficiencies.
Deficiencies (4)
| Description |
|---|
| Appliance plugged into a power strip found in activities Coordinators office. |
| Facility did not provide paperwork to establish a schedule for inspection of Fire-Rated construction. |
| Missed Annual Fire Extinguisher found in pantry. |
| Missed Annual Fire Extinguisher found in AL kitchen. |
Report Facts
Next inspection scheduled date: Feb 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Signed as the inspecting officer |
Inspection Report
Follow-Up
Census: 23
Deficiencies: 8
Feb 20, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 02/20/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, and the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to Medicaid policy disclosure, video monitoring, water temperature, maintenance and housekeeping, safe storage of supplies, and pet policy were corrected.
Deficiencies (8)
| Description |
|---|
| Failure to ensure that 23 of 23 residents were given a copy of the facility's policy regarding Medicaid as a payment source with signed acknowledgment. |
| Failure to ensure video monitoring cameras were not focused on areas where residents gathered, violating privacy. |
| Failure to maintain hot water temperature at resident-accessible sinks at no greater than 120 degrees Fahrenheit, placing residents at risk of injury. |
| Failure to ensure mechanical ventilation functioned properly in assisted living common areas, including restrooms and laundry rooms. |
| Failure to provide a safe, sanitary, and well-maintained environment, including mechanical ventilation and pest control. |
| Failure to provide secure storage of potentially hazardous cleaning supplies and chemicals, placing residents at risk of injury. |
| Failure to ensure housekeeping carts containing hazardous chemicals were locked when unattended. |
| Failure to ensure pets had regular examinations and immunizations by a licensed veterinarian, placing residents at risk for infectious diseases. |
Report Facts
Residents reviewed: 23
Residents with dementia in Memory Care Unit: 10
Residents identified with dementia in Assisted Living Unit: 2
Pets sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Machado | Community Complaint Investigator | Department staff who did on-site verification and inspection |
| Michelle Yip | ALF Licensor | Department staff who did on-site verification and inspection |
| Kathy Young | Licensor | Department staff who did on-site verification and inspection |
| Staff A | Executive Director | Interviewed regarding Medicaid policy and pet records |
| Staff G | Director of Plant Operations | Interviewed regarding video monitoring and water temperature issues |
| Staff H | Maintenance Supervisor | Interviewed regarding water temperature checks and mechanical ventilation |
| Staff J | Interviewed regarding water temperature readings | |
| Staff K | Housekeeper | Interviewed regarding housekeeping cart security |
| Staff L | Housekeeper | Observed leaving unsecured housekeeping cart |
| Staff M | Director of Nursing | Interviewed regarding residents at risk of cognitive impairment and hazardous chemicals |
Inspection Report
Life Safety
Deficiencies: 2
Dec 28, 2022
Visit Reason
An unannounced Fire and Life Safety Code inspection was conducted to determine compliance with applicable codes and regulations.
Findings
The facility's fire alarm system was found to be in deficient status due to multiple deficiencies, and the facility was unable to provide documentation for the required weekly/visual inspections of the generator for the past 12 months.
Deficiencies (2)
| Description |
|---|
| The facility's fire alarm is in deficient status due to multiple deficiencies. |
| The facility was unable to provide documentation for the required weekly/visual inspections of the generator as required by NFPA 110 for the last 12 months. |
Report Facts
Timeframe for missing generator inspection documentation: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Patton | Director of Plant Operations | Named as Owner or Authorized Representative in the inspection report |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report |
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