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Source: WA Dept. of Social & Health Services
Follow-up inspection following previous citation on 01/09/2025 regarding food sanitation.; Licensee is COMMUNITY HOUSE MENTAL HEALTH AGENCY.
The facility failed to ensure 1 of 6 sampled staff members had a valid Washington State name and date of birth background check.
Multiple food items in the refrigerator were not marked with the date opened or prepared. A bottle of salad dressing had an expired best buy date.
Wet mops were stored in buckets of dirty water. A common bathroom had a strong urine odor, grime buildup, missing plaster, and damaged wall and door surfaces.
Facility failed to ensure ready-to-eat food was labeled, dated, and safe for consumption; multiple items expired or lacked date labeling.
Facility inspection conducted 07/11/2024 and 09/23/2024 were 'Disapproved'. The final status on 12/31/2024 is 'Approved', noting previous violations have been corrected.; Approval Status: Disapproved. Next inspection scheduled on or after: 08/12/2024.
Fire extinguisher found with corrosion; hand sanitizer dispenser located too close to extinguisher.
No documentation of annual fire door inspection; resident door #3 failed to close and latch.
Carbon monoxide alarms and detectors not being tested/maintained on a monthly schedule.
Missing documentation for 12 months of fire drills; specific quarters missed for all 3 shifts.
Missing annual report, sensitivity testing, and monthly alarms test. Need policy for fire alarm status with monitoring company.
Missing required inspection/testing documentation including annual report, annual forward flow test, and quarterly inspections.
Follow-up inspection on 2025-01-02 found no deficiencies and that the identified items were corrected.
Facility failed to ensure compliance with the Washington State Patrol Office of State Fire Marshal (OSFM) following a failed fire and life safety inspection, specifically missing documentation for fire alarm testing, carbon monoxide detection, and sprinkler system maintenance.
Facility status is 'Disapproved'. Facility must develop policy for fire alarm communication and ensure staff can contact 911 in an emergency.
Missing annual reports and proof of various required tests (5-year pipe testing, 3-year dry system full flow, annual trip/flow tests, 5-year FDC hydro, quarterly inspections).
Missing documentation for monthly testing and maintenance of CO alarms/detectors.
Facility needs to establish a schedule for inspection of fire-resistance-rated construction.
Missing annual report, sensitivity testing, and monthly alarm tests; system in yellow status and unable to communicate with monitoring company.
Annual 90-minute power test not performed/documented.
Missing documentation for 30-second monthly activation tests.
Missing records for first and second semi-annual servicing.
Fire extinguisher has corrosion on body; hand sanitizer and extinguisher need relocation away from each other.
Facility could not provide documentation for completion of 12 planned and unannounced fire drills in the previous 12 months; multiple shifts missing for quarters 1-4.
No annual fire door inspection schedule established; Resident door #3 failed to close and latch.
Initial inspection on 7/5/2023 was 'Disapproved'. Follow-up inspection on 8/14/2023 indicates all previous violations have been corrected.
Missing semi-annual servicing records and annual replacement of fusible links/sprinkler heads.
Improper use of extension cords observed in the basement office.
Missing annual service, weekly logs, and monthly 30-minute load test logs.
Need to establish if dampers are present and perform required 4-year inspection.
Fire alarm circuit breaker in the electrical room is missing the required locking device.
Missing annual report and sensitivity testing documentation.
Need to establish inspection schedule and perform annual fire door inspections.
Lack of inspection schedule and annual inspection records for fire-rated construction.
Paperwork for first semi-annual hood cleaning not provided.
Missing various maintenance records, including 5-year internal pipe testing, dry system testing, flow tests, backflow testing, and quarterly inspections.
Missing documentation for CO alarm maintenance; need to add detectors in the kitchen and basement.
Multiplug/cube adapters observed in the Administrator's Office.
Follow-up inspection on 2023-09-14 resulted in no deficiencies.
Facility failed to ensure a dietitian-approved diet manual was in place for use of food preparation for residents with prescribed specialty diets.
Staff E was hired as a Caregiver on 06/15/2017 and did not have documented tuberculosis screening in their records.
The document states that all violations noted during previous related inspection(s) have been corrected and the approval status is Approved.
This letter constitutes a formal notice of a $300.00 civil fine for the cited violation.
The licensee failed to ensure ready-to-eat food was labeled, dated, and safe for residents to consume, placing 15 residents at risk for food borne illnesses. This is an uncorrected deficiency previously cited on January 9, 2025.
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