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Page 1: 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

This document was prepared by Residential Care Services for the Locator website.

Page 2: 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

This document was prepared by Residential Care Services for the Locator website.

Page 3: 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

This document was prepared by Residential Care Services for the Locator website.

Page 4: 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

This document was prepared by Residential Care Services for the Locator website.

Page 5: 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

This document was prepared by Residential Care Services for the Locator website.

Page 6: 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

This document was prepared by Residential Care Services for the Locator website.

Page 7: 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

This document was prepared by Residential Care Services for the Locator website.

Page 8: 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

This document was prepared by Residential Care Services for the Locator website.

Page 9: 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

This document was prepared by Residential Care Services for the Locator website.

Page 10: 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

This document was prepared by Residential Care Services for the Locator website.

Page 11: 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

This document was prepared by Residential Care Services for the Locator website.

Page 12: 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

This document was prepared by Residential Care Services for the Locator website.

Page 13: 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

This document was prepared by Residential Care Services for the Locator website.

Page 14: 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

This document was prepared by Residential Care Services for the Locator website.

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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

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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 · 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 · 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 · 2019-08-22 · Record review revealed Volunteer A had a Washington State Name and Date of Birth background check and no documentation

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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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · qualifications. Allegation Summary: 1) Prior to fall, Named Resident recognized need to toilet and walked with and without assistive

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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

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...Page 2 of 4 License #: 630300 COLE ADULT FAMILY HOME Licensee: ELSIE COLE Completion Date August 19, 2019 WAC 388-76-10355 Negotiated

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

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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

dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2020. 1. 2. · Fire Protection Bureau Phone: (360) 596-3900 August 20, 2019 The Office of the State Fire Marshal conducted an

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

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