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Source: AZ State Licensing Agency
The following deficiencies were found during the on-site investigation of complaints 00157708, 00157711, and 00145284 conducted on February 10, 2026:
Based on documentation review, observation, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411, for two of three personnel records requested for review. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: “C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. and 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459…” 2. The compliance officer observed E3 enter and exit resident rooms, providing assistance as the only caregiver on the premises. The compliance officer observed E4 cleaning the windows. 3. A review of personnel records revealed E3 and E4 did not have a personnel records. No documentation was provided on previous employers or of documented, good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, for E3 and E4. 4. In an interview, E1 and E2 reported E3 started working at the facility on Saturday, February 7, 2026, three days prior to the on-site inspection. No documentation was provided that the governing authority checked the Adult Protective Services (APS) Registry for E3. 5. In an interview, E1 and E2 reported E4 worked as a housekeeper twice per month; however, E1 and E2 were unsure of a starting date of employment. No documentation was provided that the governing authority checked the APS Registry for E4. 6. A review of the Arizona Department of Economic Security, Adult Protective Services (APS) Registry at https://hsapps.azdhs.gov/ls/sod/SearchAPS.aspx?type=APS revealed E3 and E4 were not on the APS registry. 7. In an interview, the findings were reviewed with E1 and E2 and no additional information was provided.
Based on observation and interview, the manager failed to ensure a personnel record for each employee included evidence of documentation outlined in R9-10-806(C)(1)(a-c) as required, for two of three personnel records requested for review. The deficient practice posed a risk as required information could not be verified. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the personnel records for E3 and E4. E3 and E4 were the two personnel on the premises when the Compliance Officer arrived. 2. In an interview, E1 advised there was no personnel record for E3 or E4. E2 reported E3 began work in the facility three days prior to the inspection. E2 reported E4 worked as a housekeeper twice per month; however, E2 was unsure of the starting date of employment. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.
Based on observation, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA) for one of three personnel records requested for review. The deficient practice posed a risk if E3 was not able to meet the needs of residents. Findings include: 1. During the on-site inspection, the Compliance Officer observed E3 providing assisted living services to residents. 2. The Compliance Officer requested to review the personnel record for E3. 3. In an interview, E1 advised there was no personnel record for E3. E1 reported E3 did not complete a caregiver training program approved by the Department or the NCIA. E2 reported E3 was a “one on one”, not a licensed caregiver. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.
Based on observation and interviews, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. The Compliance Officer was greeted by E3 upon arrival at the facility. E3 was the only caregiver on the premises when the Compliance Officer arrived at the facility. E3 advised the facility had six residents. E3 assisted residents while this Compliance Officer started the inspection of the facility. 2. The Compliance Officer observed E1 and E2 arrive on the premises after approximately 15 minutes. 3. In an interview, E2 reported E3 began work in the facility three days prior to the inspection. E2 further reported E3 was not a certified caregiver. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.
No deficiencies were found during the on-site compliance inspection conducted on November 19, 2025.
On June 26, 2025, an on-site initial inspection was completed.
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