Inspection Reports for
TJ’s Assisted Living & Memory Care
6915 Chris Ln, Flagstaff, AZ 86004, Flagstaff, AZ, 86004
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jan 22, 2026
Summary
The facility was fined $500.00 which has been paid in full as part of the enforcement resolution.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine imposed as part of enforcement action | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Dec 15, 2025
Summary
The facility was found deficient in ensuring caregiver CPR training documentation, posing a risk to resident safety during emergencies, resulting in a civil fine.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to ensure a caregiver provided current documentation of CPR training including demonstration of CPR ability before providing assisted living services. | — |
Inspection Report
Annual Inspection
Capacity: 5
Deficiencies: 15
Date: Apr 4, 2024
Visit Reason
Inspection history summary covering multiple inspections for TJ'S ASSISTED LIVING FACILITY LLC
Findings
Seventeen deficiencies were found during the on-site compliance inspection conducted on April 4, 2024, including failures in staff training, emergency responder documentation, policy reviews, reporting, documentation retention, resident service plans, medication administration, disaster planning and drills, evacuation drills, smoke detector testing, and tuberculosis screening.
Deficiencies (15)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition — failure to administer staff training program
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document — failure to ensure standardized emergency responder patient information form
C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed — failure to review and update policies
A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about ... — failure to submit documented report
A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and a... — failure to maintain documentation
B. A manager of an assisted living home shall ensure that: 1. An individual residing in an assisted living home, who is not a resident, a manager, a c... — failure to ensure records for non-residents
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — failure to review and update resident service plans
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided... — failure to obtain required documentation for directed care residents
B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administr... — failure to review and approve medication administration policies
F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, c... — failure to store medications in locked area
A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months; — failure to review disaster plan annually
A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; — failure to conduct and document disaster drills quarterly
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and — failure to conduct evacuation drills semiannually
F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedro... — failure to test smoke detectors monthly
R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this C... — failure to establish and implement tuberculosis infection control activities
Report Facts
Total inspections: 1
Total deficiencies: 17
Complaint inspections: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| THERESA GALLEGOS | Administrator | Named as Administrator in facility information |
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