THE ENCLAVE AT CHANDLER SENIOR LIVING

Assisted Living Center | Assisted Living

Facility Information

Address 4950 West Chandler Boulevard, Chandler, AZ 85226
Phone 4809403383
License AL10888C (Active)
License Owner CHANDLER 2 OPERATOR, LLC
Administrator MARCIA TURNER
Capacity 115
License Effective 8/1/2025 - 7/31/2026
Services:
3
Total Inspections
9
Total Deficiencies
3
Complaint Inspections

Inspection History

INSP-0090520

Complete
Date: 11/21/2024
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2024-12-18

Summary:

The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00218442, AZ00214094, AZ00210014, AZ00205230, AZ00204750, and AZ00204668 conducted on November 21, 2024:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document
A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:
1. The reason or reasons the emergency responder was requested on behalf of the resident.
2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.
3. The name, address and telephone number of the resident's current pharmacy.
4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.
5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.
6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.
7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.
8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act r
Evidence/Findings:
Based on documentation review, record review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. \'a7 36-420.04, for one of one applicable resident sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.

Findings include:

1. A review of facility documentation revealed an incident report dated November 6, 2024. The incident report revealed the facility called emergency medical services due to R2 exhibiting out-of-control behavior and was transported to Chandler Regional Medical Center.

2. A review of R2's medical record revealed no documentation of the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9).

3. In an interview, E1, E8, and E9 acknowledged the documentation provided to emergency medical services did not include all the information required in A.R.S. \'a7 36-420.04.

INSP-0090518

Complete
Date: 10/26/2023 - 10/27/2023
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2023-11-16

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00193773 conducted on October 26-27, 2023:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of one sampled resident who was storing medications in the resident's unit, which posed a health and safety risk.

Findings include:

1. In interview, E2 reported that R1 was allowed to manage R1's own medications.

2. R1's current service plan dated July 24, 2023 failed to state how R1's medications would be stored and controlled in R1's unit.

3. In an interview, E2 acknowledged the sampled resident was allowed to self-administer R1's own medications, however, R1's service plan did not include how R1's medications would be stored and controlled.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
3. Documentation of the disaster plan review required in subsection (A)(2) includes:
a. The date and time of the disaster plan review;
b. The name of each employee or volunteer participating in the disaster plan review;
c. A critique of the disaster plan review; and
d. If applicable, recommendations for improvement;
Evidence/Findings:
Based on documentation review and interview, the manager failed to ensure there was the required documentation of the annual disaster plan review.

Findings included:

1. At the beginning of the compliance inspection E1 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was provided documentation of the annual disaster plan meeting that was dated July 6, 2023. There was no documentation that included the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.

2. In an interview, E1 acknowledged the disaster plan meeting was lacking the required documentation.

Technical assistance was provided during the compliance inspection conducted on October 26-27, 2022.

Deficiency #3

Rule/Regulation Violated:
A. A manager shall ensure that:
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and
Evidence/Findings:
Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of the facility's documentation revealed evacuation drills were conducted on July 20, 2023 and October 13, 2023 during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during the past 12 months.

2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.

Deficiency #4

Rule/Regulation Violated:
A. A manager shall ensure that:
3. Garbage and refuse are:
a. Stored in covered containers lined with plastic bags, and
Evidence/Findings:
Based on observation and interview, the manager failed to ensure that garbage and refuse were stored in covered containers.

Findings include:

1. During a facility tour, in the memory care's prep kitchen, E2 and the compliance officer observed a large uncovered gray trash bin half-full of trash sitting next to the prep food counter. This trash container was not in use at the time of the observation.

2. In an interview, E1 and E2 acknowledged the uncovered trash.

Deficiency #5

Rule/Regulation Violated:
A. A manager shall ensure that:
6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;
Evidence/Findings:
Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents.

Findings include:

1. During a facility tour of randomly selected residents' areas, E2 and the compliance officer observed in R3's, R4's, and R5's bathrooms the hot water registered on the compliance officer's thermometer from 122.9 to 125.6\'ba F.

2. In an interview, E2 acknowledge the facility's hot water was over 120\'ba F in areas of the facility that were used by residents.

Deficiency #6

Rule/Regulation Violated:
A. A manager shall ensure that:
9. Soiled linen and soiled clothing stored by the assisted living facility are maintained separate from clean linen and clothing and stored in closed containers away from food storage, kitchen, and dining areas;
Evidence/Findings:
Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers, which posed a health risk.

Findings include:

1. During a facility tour, E2 and the compliance officer observed in the facility's memory care laundry room there was stored an open uncovered large basket full of soiled linen sitting on the floor of the laundry room. An employee reported the laundry needed washing.

2. In an interview, E2 acknowledged the soiled linen in the memory care laundry room that was not being stored in a closed container as required.

Deficiency #7

Rule/Regulation Violated:
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/Findings:
Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were maintained in a locked area, which posed a health and safety risk.

Findings include:

1. During a facility tour of the memory care unit, E2 and the compliance officer observed the unlocked memory care central laundry room there was stored in an unlocked cabinet bathroom cleaner and glass cleaner.

2. In an interview, E2 acknowledged the unlocked poisonous or toxic materials.

INSP-0090516

Complete
Date: 3/31/2023
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2023-04-11

Summary:

An on-site investigation of complaint AZ00190560 was conducted on March 31, 2023 and the following deficiency was cited:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:
B. A manager shall ensure that:
1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility,
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented; for one of two sampled residents' records reviewed, which posed a safety risk.

Findings include:

1. Review of R2's record, based on their date of acceptance, revealed there was no documentation indicating the sampled resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility.

2. During an interview, E2 reported, "not done". E1 and E2 acknowledged there was no documentation to indicate the sampled resident had received evacuation orientation to the exits from the facility within 24 hours after the residents' acceptance, nor anytime since.

Data sourced from AZ CareCheck - Arizona Department of Health Services

Report generated: 2025-11-27T19:05:38.299Z