Inspection Report Summary
The most recent inspection on November 14, 2025, identified deficiencies related to documentation, medication storage, and safety protocols, resulting in a civil fine of $2,750. Earlier inspections showed a pattern of similar issues, including incomplete service plans, personnel record deficiencies, and medication administration concerns. Enforcement actions and fines have been imposed multiple times, with the facility paying fines totaling several thousand dollars, but license suspensions or revocations were not listed in the available reports. Complaint investigations mostly found deficiencies related to caregiver qualifications, training, and documentation, with no substantiated complaints involving immediate jeopardy. The inspection history indicates ongoing challenges with regulatory compliance, particularly in documentation and staff management, with no clear trend of sustained improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Enforcement Action
Enforcement
Fines: 7
Total: $2,750.00
Date: Nov 14, 2025
Summary
The enforcement resulted in a total civil fine of $2750.00 for repeated health and safety violations, including failure to maintain emergency documentation, service plans, medication storage, and toxic material safety.
Fines & Penalties (7)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to maintain emergency documentation for responders posing risk to resident health and safety. | — |
| $250.00 | Failure to provide tuberculosis freedom documentation for employees posing TB exposure risk. | — |
| $250.00 | Failure to include medical or health problem documentation in residents' service plans. | — |
| $250.00 | Failure to include amount, type, and frequency of assisted living services in service plans. | — |
| $1,000.00 | Failure to ensure caregiver assistance with daily living activities was properly documented and verified. | — |
| $250.00 | Failure to store medication in a separate locked area posing risk to residents. | — |
| $250.00 | Failure to store toxic materials in a locked and inaccessible area posing risk to resident health and safety. | — |
Inspection Report
Modification
Capacity: 74
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
Off-site desktop review completed to change licensed capacity from 89 directed care to 30 directed care and 44 personal care. No deficiencies cited.
Findings
Off-site desktop review completed to change licensed capacity from 89 directed care to 30 directed care and 44 personal care. No deficiencies cited.
Enforcement Action
Enforcement
Fines: 1
Total: $8,800.00
Date: Apr 1, 2025
Summary
The facility was fined $8,800.00 which has been fully paid as of the completion date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $8,800.00 | Financial penalty related to enforcement action | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $7,850.00
Date: Feb 18, 2025
Summary
The enforcement resulted in a fine which has been fully paid as of the completion date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $7,850.00 | Fine related to enforcement action against the facility | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $8,800.00
Date: Jan 31, 2025
Summary
The facility was found to be non-compliant with regulations requiring a certified assisted living facility manager, posing a health and safety risk.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $8,800.00 | Failure to designate a manager with the required certificate as an assisted living facility manager, posing a health and safety risk. | — |
Enforcement Action
Enforcement
Total: $0.00
Date: Jan 3, 2025
Summary
The investigation found multiple violations including failure to ensure proper training on tuberculosis signs, lack of designated qualified managers, inadequate caregiver skill verification, and failure to maintain proper written service plans for residents.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 19
Date: Jan 3, 2025
Visit Reason
On-site investigation of multiple complaints revealed 21 deficiencies including failures in emergency responder documentation, manager designation, service plan completeness, medication documentation, and tuberculosis screening training.
Complaint Details
Investigation of complaints AZ00220663, AZ00218096, and AZ00217451
Findings
On-site investigation of multiple complaints revealed 21 deficiencies including failures in emergency responder documentation, manager designation, service plan completeness, medication documentation, and tuberculosis screening training.
Deficiencies (19)
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document — failure to provide required documentation to emergency responders
A. A governing authority shall: 3. Designate, in writing, a manager who: b. Has required certification — failure to designate a qualified manager
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented — failure to verify caregiver skills before service
A. A manager shall ensure that: 8. Personnel expected to have >8 hours/week direct resident interaction are properly managed — failure to ensure proper personnel management
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes description of medical/health problems — failure to ensure complete service plans
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes level of service expected — failure to ensure service plan completeness
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes amount, type, and frequency of services — failure to ensure service plan completeness
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is signed and dated when updated — failure to ensure updated service plans are signed
C. A manager shall ensure that: 1. A caregiver or assistant caregiver provides services according to the resident's service plan — failure to provide services as planned
B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration — failure to ensure resident dignity and respect
F. In addition to R9-10-808(A)(3), a manager shall ensure service plans for personal care include skin maintenance to prevent/treat injuries — failure to include skin maintenance in service plans
C. In addition to R9-10-808(A)(3), a manager shall ensure service plans for directed care include skin maintenance — failure to include skin maintenance in service plans
C. In addition to R9-10-808(A)(3), a manager shall ensure service plans include retaining residents confined to bed/chair — failure to obtain required documentation
C. In addition to R9-10-808(A)(3), a manager shall ensure service plans include coordination of care — failure to ensure coordinated care
C. In addition to R9-10-808(A)(3), a manager shall ensure service plans include documentation of services provided — failure to document services
F. A manager of an assisted living facility authorized to provide directed care services shall ensure means of exiting facility control or alert employees — failure to ensure exit controls
B. A manager shall ensure medication administered to a resident is documented in the medical record — failure to document medication administration
D. When a resident has an accident, emergency, or injury requiring medical services, a manager shall ensure caregiver notification and documentation — failure to ensure notification and documentation
R9-10-113. Tuberculosis Screening — failure to ensure training and education related to TB signs and symptoms
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Aug 30, 2024
Visit Reason
On-site investigation of complaint AZ00215333 found 1 deficiency related to failure to ensure personnel records included documentation of caregiver certification.
Complaint Details
Investigation of complaint AZ00215333
Findings
On-site investigation of complaint AZ00215333 found 1 deficiency related to failure to ensure personnel records included documentation of caregiver certification.
Deficiencies (1)
C. A manager shall ensure personnel records include documentation of caregiver certification — failure to document caregiver certification
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Aug 30, 2024
Summary
The facility was found to have deficient practices related to personnel records, posing a health and safety risk and providing false or misleading information to the Department.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to ensure personnel records included documentation of caregiver certification, posing health and safety risks and providing false or misleading information. | Pending |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
On-site investigation of complaints AZ00213433 and AZ00213437 found 1 deficiency for failure to develop a fall prevention and recovery training program.
Complaint Details
Investigation of complaints AZ00213433 and AZ00213437
Findings
On-site investigation of complaints AZ00213433 and AZ00213437 found 1 deficiency for failure to develop a fall prevention and recovery training program.
Deficiencies (1)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — failure to develop and administer fall prevention training
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 2
Date: Jul 17, 2024
Visit Reason
On-site investigation of complaint AZ00213148 found 2 deficiencies related to fall prevention training and failure to ensure alert systems were available.
Complaint Details
Investigation of complaint AZ00213148
Findings
On-site investigation of complaint AZ00213148 found 2 deficiencies related to fall prevention training and failure to ensure alert systems were available.
Deficiencies (2)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — failure to develop and administer fall prevention training
E. A manager shall ensure bell, intercom, or other mechanical means to alert employees to resident needs or emergencies is available and accessible — failure to ensure alert system availability
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 7
Date: May 7, 2024
Visit Reason
Compliance inspection and investigation of multiple complaints found 7 deficiencies including failures in emergency responder documentation, medication administration policies, disaster plan documentation, disaster drills, and toxic material storage.
Complaint Details
Investigation of complaints AZ00209561, AZ00205914, AZ00204019, AZ00203757, and AZ00197831
Findings
Compliance inspection and investigation of multiple complaints found 7 deficiencies including failures in emergency responder documentation, medication administration policies, disaster plan documentation, disaster drills, and toxic material storage.
Deficiencies (7)
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document — failure to provide required documentation to emergency responders
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is signed and dated when initially developed and updated — failure to ensure signed service plans
B. If an assisted living facility provides medication administration, a manager shall ensure policies and procedures include documentation process — failure to ensure medication policies
F. When medication is stored by an assisted living facility, a manager shall ensure medication is stored in a locked area — failure to secure medication storage
A. A manager shall ensure disaster plan review documentation includes date/time and employee names — failure to document disaster plan review properly
A. A manager shall ensure disaster drills for employees are conducted on each shift at least once every three months and documented — failure to conduct/document drills
A. A manager shall ensure poisonous or toxic materials are stored in labeled containers in a locked area inaccessible to residents — failure to secure toxic materials
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jul 25, 2023
Summary
A fine of $500.00 was imposed and has been paid in full.
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: Jul 12, 2023
Summary
The facility was found deficient in maintaining complete personnel records for caregivers and documenting services provided to residents, resulting in civil fines totaling $500.00.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Civil fines for failure to maintain proper personnel records and documentation of services provided to residents. | Pending |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 5
Date: Jul 12, 2023
Visit Reason
On-site investigation of multiple complaints found 6 deficiencies related to caregiver qualifications, personnel record documentation, service documentation, and resident service plans.
Complaint Details
Investigation of complaints AZ00197063, AZ00197245, AZ00197688, and AZ00197693
Findings
On-site investigation of multiple complaints found 6 deficiencies related to caregiver qualifications, personnel record documentation, service documentation, and resident service plans.
Deficiencies (5)
A. A manager shall ensure assisted living facility has caregivers with required qualifications, experience, skills, and knowledge — failure to ensure qualified caregivers
C. A manager shall ensure personnel records include documentation of qualifications, skills, knowledge, education, experience, orientation, and TB freedom — failure to maintain complete personnel records
C. A manager shall ensure that: 1. A caregiver or assistant caregiver documents services provided in resident's medical record — failure to document services
F. In addition to R9-10-808(A)(3), a manager shall ensure service plans for personal care include skin maintenance to prevent/treat injuries — failure to include skin maintenance in service plans
C. In addition to R9-10-808(A)(3), a manager shall ensure service plans for directed care include skin maintenance — failure to include skin maintenance in service plans
Enforcement Action
Enforcement
Fines: 2
Total: $750.00
Date: Jun 29, 2023
Summary
The facility failed to implement proper medication administration policies and did not maintain adequate personnel records, resulting in a risk to residents and inability of the Department to determine substantial compliance.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to implement policies and procedures covering medication administration. | — |
| $250.00 | Failure to ensure personnel records included documentation of skills and knowledge for two caregivers. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $750.00
Date: Jun 20, 2023
Summary
The enforcement resulted in a fine of $750.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $750.00 | Fine associated with enforcement action #00113165 | Paid |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 5
Date: Jun 5, 2023
Visit Reason
Compliance inspection and investigation of complaint AZ00193335 found 11 deficiencies including failures in fall prevention training, policy implementation, documentation, personnel records, and resident orientation.
Complaint Details
Investigation of complaint AZ00193335
Findings
Compliance inspection and investigation of complaint AZ00193335 found 11 deficiencies including failures in fall prevention training, policy implementation, documentation, personnel records, and resident orientation.
Deficiencies (5)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — failure to develop and administer fall prevention training
C. A manager shall ensure that policies and procedures are established, documented, implemented, and reviewed at least every three years — failure to implement and review policies
E. A manager shall ensure documentation required by Article 8 is provided to the Department within two hours after request — failure to provide documentation timely
C. A manager shall ensure personnel records include documentation of qualifications, skills, knowledge, education, experience, orientation, and TB freedom — failure to maintain complete personnel records
B. A manager shall ensure residents receive orientation to facility exits and evacuation routes — failure to provide resident orientation
Inspection Report
Original Licensing
Capacity: 74
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
Off-site initial inspection for change of ownership found no deficiencies.
Findings
Off-site initial inspection for change of ownership found no deficiencies.
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement 2
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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