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Page 1: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 2: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 3: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 4: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 5: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 6: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 7: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 8: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 9: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 10: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 11: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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Page 12: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019-10-15 · DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, suite 400,

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Residential Care Services, Region 2, Unit E 20425 72nd Avenue S, Suite 400 Kent, WA 98032-2388 (253)234-6033 As a result of the

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...Paradise Care Adult Family Home 2 Licensee: NORMA BALI You are required to be in compliance with all of the licensing laws and regulations

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Amber Waves ALF LLC (878473) Intake ID(s): 3687978 License/Cert. #: AL2324 Investigator: Webster, Brenda Region/Unit:RCS

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · The sidewalks on either side of the patio had accumulated about an inch of snow that had not been removed. On 02/08/19 at 1 1 :08

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] Xfortress.wa.gov/dshs/adsaapps/lookup/RCSForms/AF/751087/inspections/2019/R...Observation and interview occurred on 12/4/18 between 8:45

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Residential Care Services Investigation Summary Report assessment and care plans Allegation Summary: Named resident (AV) was admitted

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2019. 10. 29. · 1) the ALF acted immediately to evaluate the resident after the fall, call ed911 for further evaluation and transportation

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Owner or Owner's Representative dZ] } µu v Á ÇZ ] v …...2153 Approved Residential Care On 04/15/2019 the Office of the State Fire Marshal conducted an inspection at your facility

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Plan of Correction Page 9 of 10 License #: 2229 CHATEAU PACIFIC RETIREMENT COMMUNITY Licensee: CP RETIREMENT LLC Completion Date

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Blue Goose Care Center LLC BLUE GOOSE CARE CENTER 7340 BLUE GOOSE RD NE MOSES LAKE, WA 98837 RE: BLUE GOOSE CARE CENTER License

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...Residential Care Services Investigation Summary Report Provider/Facility: AWA and Malick Adult Family Home LLC (1133622) Intake ID(s):

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...Resident fell out of wheel chair striking his head. Resident was left in the wheel chair while not awake for a period of time prior

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Licensee: WRG PHASE 1 Completion Date October 16, 2017 Per WAC (Washington Administrative Code) 388-112-0207(1), all long-term