ARIZONA SUNSET ASSISTED LIVING

Assisted Living Home | Assisted Living

Facility Information

Address 35605 North Moyes Road, Queen Creek, AZ 85142
Phone 4806871688
License AL10864H (Active)
License Owner ARIZONA SUNSET ASSISTED LIVING LLC
Administrator FELIZARDE T ESTRELLA
Capacity 10
License Effective 9/1/2025 - 8/31/2026
Services:
2
Total Inspections
11
Total Deficiencies
0
Complaint Inspections

Inspection History

INSP-0135752

Complete
Date: 7/8/2025
Type: Compliance (Annual)
Worksheet: Assisted Living Home
SOD Sent: 2025-07-28

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on July 8, 2025:

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:
R9-10-803.C.3. Administration<br> C. A manager shall ensure that policies and procedures are: <br>3. Reviewed at least once every three years and updated as needed.
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of the facility's policy and procedure manual revealed an update date of May 30, 2021. </p><p><br></p><p><br></p><p>2. In an interview, E2 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed. </p><p><br></p>
Permanent Solution:
Elizabeth Seymour - Administrator, acknowledges that the required review of the facility's
Policy and Procedure Manual at least once every three years had not been completed due to oversight. Upon identifying the deficiency, a medical personnel member was contacted to immediately review and update the Policy and Procedure Manual to ensure accuracy and compliance.
Person Responsible:
Elizabeth Seymourr - Administrator

Deficiency #2

Rule/Regulation Violated:
R9-10-808.A.5.a. Service Plans<br> A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: <br>5. When initially developed and when updated, is signed and dated by: <br>a. The resident or resident’s representative;
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a resident had a written service plan that when initially developed, was signed and dated by the resident or resident’s representative, for one of two residents sampled.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a service plan, dated April 16, 2025. However, the resident or resident's representative did not sign and date the service plan.</p><p><br></p><p><br></p><p>2. In an interview, E2 acknowledged R1's service plan was not signed and dated by the resident or resident's representative.</p><p><br></p>
Permanent Solution:
Elizabeth Seymour - Administrator, acknowledges that efforts to contact R1's representative were delayed due to their out-of-state employment and limited availability. Despite multiple attempts, communication was not successful by the time of the survey. Moving forward, the facility will persist in making contact through all available methods until communication is successful and documentation is complete.
Person Responsible:
Elizabeth Seymour - Administrator

Deficiency #3

Rule/Regulation Violated:
R9-10-810.B.3.b. Resident Rights<br> B. A manager shall ensure that: <br>3. A resident or the resident’s representative: <br>b. Consents to photographs of the resident before the resident is photographed, except that a resident may be photographed when accepted as a resident by an assisted living facility for identification and administrative purposes;
Evidence/Findings:
<p>Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for two of two residents sampled. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. </p><p><br></p><p><br></p><p>2. A review of R1's and R2's medical records did not contain a photographic consent form signed by the resident or resident's representative. </p><p><br></p><p><br></p><p>3. In an interview, E2 acknowledged R1's and R2's medical records did not contain consent to photographs by the resident or resident's representative before R1 and R2 were photographed. </p>
Permanent Solution:
Elizabeth Seymour - Administrator, reviewed and updated all resident medical records following the survey to ensure that the Consent to Photograph form is included in each file, including R1's. This ensures every resident's rights and preferences are appropriately documented.
Person Responsible:
Elizabeth Seymourr - Administrator

Deficiency #4

Rule/Regulation Violated:
R9-10-814.B.1-2. Personal Care Services<br> B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: <br>1. The condition is a result of a short-term illness or injury; or <br>2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: <br>a. The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; <br>b. The resident’s primary care provider or other medical practitioner: <br>i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; <br>ii. Reviews the assisted living facility’s scope of services; and <br>iii. Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility; and <br>c. The resident’s service plan includes the resident’s
Evidence/Findings:
<p>Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..."</p><p><br></p><p><br></p><p>2. A review of R2's service plan (dated January 23, 2025) revealed R2 received personal care services and was confined to a bed or chair. </p><p><br></p><p><br></p><p>3. A review of R2's medical record revealed a determination for continued residency dated November 20, 2020. However, no further documentation was available for Compliance Officer review. </p><p><br></p><p><br></p><p>4. In an interview, E2 acknowledged R2's medical record did not include the required determination per R9-10-814(B)(2) updated at least once every six months. </p><p><br></p>
Permanent Solution:
Elizabeth Seymour-Administrator, promptly requested R2's Primary Care Physician to assess and evaluate R2's condition every six months to ensure that the resident's care needs remain appropriate for the services provided within the assisted living setting. This assessment was completed to confirmed continued residency eligibility as mandated.
Person Responsible:
Elizabeth Seymour - Administrator

Deficiency #5

Rule/Regulation Violated:
R9-10-817.B.3.c. Medication Services<br> B. If an assisted living facility provides medication administration, a manager shall ensure that: <br>3. A medication administered to a resident: <br>c. Is documented in the resident’s medical record.
Evidence/Findings:
<p>Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed a medication order for Gabapentin 400 milligrams (mg), 1 tablet by mouth (po) twice a day (bid).</p><p><br></p><p><br></p><p>2. A review of R1’s medication administration record (MAR) for July 2025 revealed R1 was administered Gabapentin 400 mg, 1 tablet po daily, and indicated 1 tablet was given at 8:00 AM July 1, 2025 - present.</p><p><br></p><p><br></p><p>3. The Compliance Officer observed Gabapentin 400 mg prefilled in R1's medication organizer for administration bid.</p><p><br></p><p><br></p><p>4. In an interview, E2 reported R1 was administered Gabapentin 400 mg at 8:00 AM and 8:00 PM. However, E2 acknowledged medication administered to R1 was not accurately documented in R1’s medical record. </p>
Permanent Solution:
Elizabeth Seymour-Administrator, promptly addressed the issue related to medication charting procedures with the caregiver responsible for this task. Caregiver on sight underwent additional training on routine medication administration procedures. Furthermore, R1's medical record has been subjected to a thought review and correctio to ensure that it accurately reflects the prescribed medication administration. Any discrepancies or omissions have been rectified.
Person Responsible:
Elizabeth Seymour - Administrator

Deficiency #6

Rule/Regulation Violated:
R9-10-817.D.2. Medication Services<br> D. A manager shall ensure that: <br>2. A current toxicology reference guide is available for use by personnel members.
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. While on-site for the compliance inspection, the Compliance Officers requested the facility's toxicology reference guide. However, a guide was not available for review.</p><p><br></p><p><br></p><p>2. In an interview, E2 acknowledged a current toxicology reference guide was not available for use by personnel members.</p><p><br></p>
Permanent Solution:
Elizabeth Seymour - Administrator, promptly obtained a current toxicology reference guide and made it readily accessible to all facility personnel. The guide has been placed in a designated area where staff can easily access it at any time.
Person Responsible:
Elizabeth Seymour - Administrator

INSP-0060316

Complete
Date: 8/1/2023
Type: Compliance (Annual)
Worksheet: Assisted Living Home
SOD Sent: 2023-08-07

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on August 1, 2023:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C), for two of three caregivers sampled. The deficient practice posed a risk if E3 and E4 were a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C) Owners 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.

2. A review of E3's (hired in 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

3. A review of E4's (hired in 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review.

4. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) for E3 and E4 was not available for review.

This is a repeat deficiency from the on-site compliance inspection conducted on January 5, 2022.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;
Evidence/Findings:
Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for two of three caregivers sampled. The deficient practice posed a risk if E3 and E4 were unable to meet a resident's needs.

Findings include:

1. The Compliance Officer observed E3 and E4 on the premises and working upon arrival.

2. A review of the facility's policies and procedures revealed a policy titled "Staffing, Documentation, and Recordkeeping" (dated May 30, 2021). The policy stated "Verify employee's skill and knowledge per the job description..."

3. A review of E3's (hired in 2023) personnel record revealed E3 was hired as a caregiver. However, documentation of the verification of E3's skills and knowledge was not available for review.

4. A review of E4's (hired in 2023) personnel record revealed E4 was hired as a caregiver. However, documentation of the verification of E4's skills and knowledge was not available for review.

5. In an interview, E1 acknowledged E3's and E4's skills and knowledge were not verified and documented prior to E3 and E4 providing physical health services and according to the facility's policies and procedures.

Deficiency #3

Rule/Regulation Violated:
C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);
Evidence/Findings:
Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix), for one of four employees and R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix), for one of four employees sampled. The deficient practice posed a risk if E3 and E4 were unable to meet a resident's needs, and the required information could not be verified for E3.

Findings include:

1. The Compliance Officer observed E3 and E4 on the premises and working upon arrival to the premises.

2. A review of E3's (hired in 2023) personnel record revealed the following:
-Name, date of birth, and contact telephone number;
-Starting date of employment;
-Education;
-Experience;
-Caregiver certificate;
-Cardiopulmonary resuscitation training (CPR); and
-First aid.
However, documentation of the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix) was not available for review.

3. A review of E4's (hired in 2023) personnel record revealed the following:
-Name;
-Caregiver certificate;
-CPR; and
-First aid.
However, documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix) was not available for review.

4. In an interview, E1 acknowledged E3's personnel record to include the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix) was not available for review.

5. In an interview, E1 acknowledged E4's personnel record to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix) was not available for review.

Deficiency #4

Rule/Regulation Violated:
F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that:
2. A life preserver or shepherd's crook is available and accessible in the swimming pool area; and
Evidence/Findings:
Based on observation and interview, the manager failed to ensure a life preserver or shepherd's crook was available and accessible in the swimming pool area.

Findings include:

1. The Compliance Officer observed a swimming pool on premises, in the back yard. The swimming pool contained water. However, a life preserver or shepherd's crook was not available or accessible in the swimming pool area.

2. In an interview, E1 reported residents and personnel do not use the pool. E1 acknowledged the facility did not have a life preserver or shepherd's crook available in the swimming pool area.

Deficiency #5

Rule/Regulation Violated:
F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that:
3. Pool safety requirements are conspicuously posted in the swimming pool area.
Evidence/Findings:
Based on observation and interview, the manager failed to ensure pool safety requirements were conspicuously posted in the swimming pool area.

Findings include:

1. The Compliance Officer observed a swimming pool on premises, in the back yard. The swimming pool contained water. However, pool safety requirements were not conspicuously posted in the swimming pool area.

2. In an interview, E1 reported residents and personnel do not use the pool. E1 acknowledged the pool safety requirements were not conspicuously posted in the swimming pool area.

Data sourced from AZ CareCheck - Arizona Department of Health Services

Report generated: 2025-11-27T17:46:26.076Z