Inspection Report
Complaint Investigation
Capacity: 135
Deficiencies: 6
Jul 22, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-04-13 to 2025-07-22 with deficiency history and complaint investigations.
Findings
Across five inspections, no deficiencies were found in four inspections including two complaint investigations and two compliance (annual) inspections. One complaint investigation on 2024-01-09 cited six deficiencies related to management notification, caregiver documentation, skills verification, service plan signatures, service plan content, and hot water temperature.
Complaint Details
Complaint investigations were conducted on 2025-07-22, 2025-07-18, and 2024-01-09. The 2024-01-09 complaint investigation cited six deficiencies; the other two complaint investigations found no deficiencies.
Deficiencies (6)
| Description |
|---|
| A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager; - Failed to notify the Department of a change in manager until day of inspection. |
| A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: iv. For supervisory care services, personal care services, or directed services, one of the following: (1) A nursing care institution administrator's license issued by the Board of Examiners; (2) A nurse's license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a manager or caregiver of an unclassified residential care institution before November 1.1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult foster care home before November, 1998; - Failed to ensure caregiver provided valid documentation of completion of approved caregiver training. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services - Failed to verify and document caregiver skills and knowledge before providing services. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. - Failed to ensure service plans were signed and dated as required for three residents. |
| F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; 2. Offering sufficient fluids to maintain hydration; 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and 4. If applicable, the determination in subsection (B)(2)(b)(iii). - Failed to include required elements in service plans for five residents. |
| A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents; - Failed to maintain hot water temperature within required range in resident areas. |
Report Facts
Inspections on page: 5
Total deficiencies: 6
Complaint inspections: 3
Total capacity: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed and acknowledged deficiencies related to management notification, caregiver documentation, skills verification, service plan signatures, service plan content, and hot water temperature. | |
| E3 | Named as new manager effective December 23, 2023. | |
| E4 | Caregiver | Personnel record reviewed showing invalid caregiver certifications. |
| E12 | Caregiver | Personnel record lacked verified and documented skills and knowledge. |
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