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Page 1: 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

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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 · The Provider stated he had bronchitis but acknowledged and trying to was an issue since admission and the doctor had been notified

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


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 · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

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

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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

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Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · 2020. 5. 2. · MAINTENANCE REP Mike Schleigh FACILITY NAME Riverview Terrace ADDRESS 1801 E. Upriver Drive ADMINISTRATOR Charles Cirell PHONE

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 · Provider/Facility: Amber Waves ALF LLC (878473) Intake ID(s): 3687978 License/Cert. #: AL2324 Investigator: Webster, Brenda Region/Unit:RCS

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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This do cument Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...During an interview on 12/26/19 at 2:20 PM, Staff A stated that the dresser in Bedroom B had ... there was a large screen television

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 · -Kitchen screen door: was made of fabric-like material with Velcro. The screen door was torn in half and exposed half of the bottom

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):

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 · (c) Mental health specialty training as described in WAC 388-112A-0450 This requirement was not met as evidenced by: Based on interview

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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

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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Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · drill were not documented. The date 05/15/18 was written on a sample fire drill form but the form was not completed During the exit interview

Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X...Statement of Deficiencies Plan of Correction Page 2 of 14 License 750457 MILES ADULT FAMILY HOME Licensee: MILES ADULT AND SENIOR CARE LLC Completion

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 ] 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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