Inspection Details
Inspection #
INSP-0100418
Inspection Date(s)
3/6/2025
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL11228H
Location Type
—
Initial Comments
The following deficiencies were found during the on-site compliance inspection conducted on March 6, 2025:
Statement of Deficiency
2 deficiencies found
Deficiency #1
R9-10-806
✓ Plan Provided
▼
Rule
R9-10-806.A.8.a-b. Personnel
A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;
Evidence
Plan of Correction
Responsible Person
Kori Zarinegar Owner/ Manager
Temporary Correction Date
2025-03-22
Permanent Correction Date
2025-03-22
Temporary Solution
Employee did have a current freedom from TB on file. Employee E3 was immediately scheduled for the second TB skin test, which was completed on 3/22/25 Documentation of both TB tests has been added to E3’s personnel file.
Permanent Solution
Systemic Procedure have been and are currently in place: TB Testing Policy TB screening and documentation policy has been implemented, requiring all new employees to complete and provide proof of a two-step TB test before their start date. A hiring compliance checklist Is in place to ensure all required documents, including TB tests, are completed before an employee begins working. On New Hires going forward, Kori Zarinegar will Scan and electronically file TB tests Employee Files were audited on 3/22/25 checking for any missing or incomplete TB records. Staff Training: On 3/21/22, manager and Admin assistant held a training on the Arizona Department of Health Services (ADHS) TB testing requirements. Stressing the 2 part TB testing , not just seeking to find only a current TB during a file audit.
Monitoring
A quarterly audit of all employee files are conducted to ensure compliance with TB testing requirements. Kori Zarinegar ( manager) will oversee compliance with this corrective action plan and ensure all new hires meet TB testing requirements before their start date
Deficiency #2
R9-10-819
✓ Plan Provided
▼
Rule
R9-10-819.A.11. Environmental Standards
A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Evidence
Plan of Correction
Responsible Person
Kori Zarinegar Owner/ Manager
Temporary Correction Date
2025-03-06
Permanent Correction Date
2025-03-23
Temporary Solution
The Lysol bottle and unlabeled blue liquid were removed from the unlocked bathroom cabinet and relocated to a designated, locked storage area. The blue liquid was properly labeled as “Glass Cleaner” to ensure compliance
Permanent Solution
Policy Checked to Ensure it states: All Toxic Material Storage Policy has been reinforced, requiring all cleaning supplies, disinfectants, and chemicals to be stored in locked cabinets at all times. Staff have been instructed that all unlabeled liquids are prohibited and must be properly labeled if stored on-site. On 3/23/25 all staff were instructed on toxic material storage requirements and how to properly label and secure cleaning supplies
Monitoring
The manager : Kori Zarinegar will conduct Frequent unannounced environmental safety checks to ensure all toxic materials remain properly stored. Any non-compliance will be addressed immediately with additional corrective actions. Designated Caregiver : Maria Hernandez will oversee daily compliance with this corrective action plan and ensure staff adhere to the Home's policies regarding toxic materials.