Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Follow-Up
Census: 33
Deficiencies: 2
Sep 15, 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 related to tuberculosis skin testing and pet certification were corrected.
Deficiencies (2)
| Description |
|---|
| Failed to ensure 1 of 5 sampled staff received a two-step tuberculosis test with the second step placed one to three weeks after the first test, placing 33 residents at risk. |
| Failed to ensure that 2 of 3 pets obtained certification from a veterinarian to confirm they did not carry diseases transmittable to humans, placing 33 residents at risk. |
Report Facts
Residents present: 33
Sampled staff: 5
Pets: 3
Days between TB tests: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Technician/Caregiver | Named in tuberculosis skin testing deficiency |
| Staff F | Executive Director | Acknowledged tuberculosis test spacing findings during interview |
| Staff G | Resident Care Manager | Involved in obtaining pet health letters |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Nov 5, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding medication delivery delays and failure to deliver a message to a resident to plug in their cell phone.
Findings
The Assisted Living Facility failed to deliver medication to a resident for four days after pharmacy delivery, due to lack of a family assistance with medication agreement, constituting a violation of regulations. The allegation regarding failure to deliver a message to the resident about their cell phone was not substantiated.
Complaint Details
The complaint alleged that the pharmacy delivered medication to the facility but the facility did not deliver it to the resident for four days, and that the facility failed to deliver a message to the resident to plug in their cell phone. The medication delivery allegation was substantiated with a citation; the cell phone message allegation was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a written plan for family assistance with medications, causing a resident to go without medication for four days. |
Report Facts
Total residents: 27
Compliance Determination Completion Dates: Completion dates 11/12/2024 and 12/19/2024 mentioned
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hauk | Complaint Investigator | Department staff who investigated the Assisted Living Facility and conducted off-site verification |
| Jamie Singer | Field Manager | Signed letters and reports related to the inspection |
| Tam Thomas | Administrator (or Representative) | Signed Plan/Attestation Statement for correction of deficiency |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 17, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 04/17/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements.
Report Facts
Complaint sample size: 6
Complaint sample size: 25
Complaint sample size: 0
Deficiency correction completion date: Completion dates for correction of deficiencies range from 02/12/2024 to 04/17/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Singer | Field Manager | Signed letters related to inspection and follow-up |
| Alma Duran | Licensor | Department staff who did on-site verification |
| Keiko Kitano | Licensor | Department staff who did on-site verification |
| Tam Thomas | Administrator (or Representative) | Signed Plan/Attestation Statements for correction of deficiencies |
| Staff F | Resident Care Manager | Interviewed regarding dementia assessments and care plans |
| Staff B | Medication Technician / Caregiver | Mentioned in relation to incomplete specialty training for dementia and mental health |
| Staff H | Executive Director | Interviewed regarding respiratory protection program and missing certifications |
| Staff K | Medication Technician | Documented medication administration and communication with licensed nurse |
| Staff I | Vice President of Operations | Responded to questions about medication administration and blood sugar monitoring |
Inspection Report
Life Safety
Deficiencies: 9
Jun 20, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Daystar at Westwood residential care facility to assess compliance with fire protection codes and regulations.
Findings
The inspection identified multiple deficiencies including storage of combustible materials in prohibited areas, use of extension cords as permanent wiring, missing covers on electrical boxes, gate hardware non-compliance, missing lock device on fire alarm circuit breaker, lack of required inspection paperwork for fire-rated construction, fire/smoke dampers, and fire doors. The facility was disapproved due to these violations.
Deficiencies (9)
| Description |
|---|
| Combustible material stored in boiler rooms, mechanical rooms, electrical equipment rooms or fire command centers |
| Extension cords used as substitute for permanent wiring and used improperly |
| Open junction boxes and open wiring without approved covers |
| Gate placed in path of egress with non-compliant hardware |
| Fire alarm circuit breaker missing required lock device to lock breaker in 'ON' position |
| Missing paperwork for inspection and maintenance of fire-rated construction and fire-resistance-rated elements |
| Missing quarterly inspections paperwork |
| Missing fire/smoke damper 4-year inspection and documentation |
| Missing annual fire door inspection and documentation |
Report Facts
Next inspection scheduled date: Jul 20, 2023
Provider Number: 924
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Edith Tidmore | Executive Director | Owner or Authorized Representative who signed the report |
Loading inspection reports...
