CLARENDALE ARCADIA

INSP-0136410

Complete

Date: 7/24/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-08-08

Summary:

No deficiencies were found during the on-site investigation of complaint 00136345 conducted on July 24, 2025.

✓ No deficiencies cited during this inspection.

INSP-0133815

Complete

Date: 6/11/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-07-21

Summary:

No deficiencies were found during the on-site investigation of complaints 00133124 and 00133149 conducted on June 11, 2025.

✓ No deficiencies cited during this inspection.

INSP-0131482

Complete

Date: 5/14/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-03

Summary:

The following deficiencies were found during the on-site investigation of complaints 00130397 and 00130398 conducted on May 14, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-815.F.1. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander;

Evidence/Findings:

Based on the documentation review and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to ensure the safety of residents who may wander. Findings include: 1. A review of Department documentation revealed AL12431 was licensed to provide directed care services. 2. A review of the facility's policies and procedures revealed that no policy was established to cover the safety of residents who may wander. The Compliance Officer was provided a document titled "Missing Resident Policy;” however, the policy did not include how the facility would ensure the safety of residents who may wander. 3. In an interview, E1 acknowledged that the "Missing Resident Policy" did not include how the facility would ensure the safety of a wandering resident.

Temporary Solution:

Immediate assessment provided to ensure the safety of the residents involved in the wandering/elopement incident. All alarms and doors checked in secured /MC unit

Permanent Solution:

Wandering/Exit seeking Policy & Procedure initiated and implemented.

See attached policy and procedure documentation.

Person Responsible:

Cristian Mendez Escobar

Deficiency #2

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on the record review, documentation review, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. 1 A review of R1's and R2’s medical records revealed that R1 and R2 received directed care services 2. A review of R1’s service plan dated May 14, 2025, revealed a section titled “wandering/ Elopement risk”, it stated that “R1 has a current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety (of self or others).” 3. A review of R2’s service plan dated March 13, 2025, revealed a section titled “wandering/ Elopement risk”, it stated that “R2 has a current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety (of self or others).” 4. A review of facility documentation revealed an incident report dated May 5, 2025. The incident report stated that “the welcome desk attendant noted that at approximately 2:55 PM, a resident walked into the community via the front door, accompanied by another resident. The resident presented no distress and asked for assistance getting back home. The welcome desk attendant immediately called the Memory Care Director to report the two Memory Care residents at the welcome desk. The Memory Care Director arrived at the front desk and escorted the residents back into Memory Care. No sign of pain or discomfort noted, no signs of distress. The resident stated I was out on a walk. Upon assessment, no injuries were noted. Further investigation revealed that the residents had walked out of Memory Care unnoticed around 2:47 PM, as witnessed by surveillance cameras, due to an unlocked door that was in use for a move-out. The door was immediately locked, and the alarms were turned on.” 5. In an Interview, E1 reported that R1 and R2 got out when the doors were used for a move-out at the facility. E1 acknowledged that there was no means of exiting the facility that controlled or alerted employees of the egress of the resident. This is a repeat deficiency from a complaint inspection conducted on June 28, 2023

Temporary Solution:

Note all egress doors in Memory Care are equipped with key fob access for staff only. Note all egress doors in Memory Care also have a sound alarm to alert staff of opening of the doors.

All egress exits were monitored and reviewed for proper functioning of alarms.

Permanent Solution:

Continue to monitor all egress doors.

Will continue frequent monitoring of egress doors to ensure proper functioning of alarms and that both key fob and sound alarms remained in ON function post move-ins or move outs.

Staff to be present at exits whenever move-ins or move outs occurred.

In-service provided for staff. See attached in service documentation.

Person Responsible:

Cristian Mendez Escobar

INSP-0102031

Complete

Date: 3/20/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-07

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00102597 and AZ00105577 conducted on March 20, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-818.A.5.a. Emergency and Safety Standards 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 facility documentation revealed documentation of an evacuation drill conducted in July 2024. However, documentation of an evacuation drill conducted after July 2024 was not available for review at the time of inspection. 2 . In an interview, E1 reported E1 had no documentation of an evacuation drill conducted after July 2024. E1 acknowledged an evacuation drill was not conducted at least once every six months as required.

Temporary Solution:

Evacuation drill scheduled for April 2025.

Permanent Solution:

Semi annual Evacuation Drill scheduled for every April & October. See attached documentation (evidence of completion).

Per community's P&P Evacuation Drills Policy Reference (PLT001PP)
1. Staff and residents shall participate in an evacuation drill at least once every 6 months.
2. Documentation of each evacuation drill is maintained for 12 months after the date of the evacuation drill.
3. Documentation shall be available for review upon request.
4. Documentation may be recorded on the fire drill record sheet with detailed information stating the evacuation process.

The above monitoring should be done by Maintenance Director with review of completion by Executive Director

Person Responsible:

Cristian Mendez-Escobar Executive Director

Deficiency #2

Rule/Regulation Violated:

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/Findings:

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet under the kitchen sink in the "Mountain Vista" common room. When the Compliance Officer pulled on the cabinet door, it was unlocked. Inside the cabinet was a bottle of "Spic and Span" disinfecting all-purpose spray. 2. During an environmental inspection of the facility, the Compliance Officers observed a door with an electronic lock with a sign next to the door labeled "Housekeeping." When the Compliance Officer pulled on the doorknob, the door opened. Inside the room was an electronic unit to dispense cleaning agents, which included "Spic and Span" disinfecting all-purpose spray, and "Mr.Clean" finished floor cleaner. 3 . During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet under the kitchen sink in the memory care kitchen area. When the Compliance Officer pulled on the cabinet door, it was unlocked. The cabinet contained the following:-A bottle of "Spic and Span" disinfecting cleaner;-A bottle of "Comet" disinfecting-sanitizing cleaner;-A can of "Scrubbing Bubbles" Multi-purpose cleaner; and-A can of "Zep" carpet and upholstery spot remover. 4 . During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet near a washer and dryer in a common area of the memory care unit. When the Compliance Officer pulled on the cabinet door, it was unlocked. Inside was a bag of "Gain Flings" laundry detergent pods. 5 . In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were accessible to residents.

Temporary Solution:

1. Observation: Mountain Vista disinfecting solution noted under lockable cabinet- Temporary solution, solution was removed and placed in appropriate locked are and lockable cabinet was locked.
2.Observation: Housekeeping Room unlocked with cleaning solutions- Temporary solution, electronic lock was reset and immediately locked.
3. Observation: Memory Care kitchen area lockable cabinet was unlocked, cleaning solution noted. Temporary solution- cabinet was immediately locked.
4. Observation: Lockable cabinet near washer and dryer memory care area unlocked with laundry detergent. temporary Solution. Detergent removed and stored in appropriate area, lockable cabinet locked.
See attached locked cabinets Image

Permanent Solution:

All cleaning chemicals/toxic materials must be stored and locked in designated areas marked as housekeeping room. See attached Image
See attached evidence of electronic lock housekeeping room and metal shelving for appropriate secured storage of poisonous or toxic materials. See attached Image.

Person Responsible:

Cristian Mendez-Escobar Executive Director

INSP-0065875

Complete

Date: 6/28/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-07-10

Summary:

An on-site investigation of complaint AZ00196887 was conducted on June 28, 2023 and the following deficiency was cited:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

F. A manager of an assisted living facility authorized to provide directed care services shall ensure that:
2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following:
a. Provides access to an outside area that:
i. Allows the resident to be at least 30 feet away from the facility, and
ii. Controls or alerts employees of the egress of a resident from the facility;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services.

2. Review of a document titled "Incident Investigation Report" dated June 17, 2023 stated "On 6/17/23 at approximately 4:00pm an Independent Living resident entered the community with (R1) and approached the front desk. The IL resident explained to the desk attendant that (the IL resident) came across (R1) in the south parking lot...Upon being notified of the elopement, the Executive Director immediately began an investigation. It was discovered that a staff member used an exit door that should not have been used and failed to ensure it was fully closed. This door is operated using a key fob and, when operating properly, automatically closes. The auto function failed in this instance, thus leaving the door ajar and allowing (R1) to exit the community and find (R1's) way to the south parking lot."

3. During an interview, E1 acknowledged on June 17, 2023, there was not a means of exiting the facility that controlled or alerted employees of the egress of R1.

INSP-0065874

Complete

Date: 4/21/2023

Type: Initial Monitoring

Worksheet: Assisted Living Center

SOD Sent: 2023-04-25

Summary:

No deficiencies were found during the on-site abbreviated initial follow-up inspection conducted on April 21, 2023.

✓ No deficiencies cited during this inspection.

INSP-0065873

Complete

Date: 2/23/2023

Type: Compliance (Initial)

Worksheet: Assisted Living Center

SOD Sent: 2023-02-24

Summary:

No deficiencies were found during the on-site initial inspection conducted on February 23, 2023.

✓ No deficiencies cited during this inspection.

Facility Information

Inspection History

INSP-0136410

Summary:

INSP-0133815

Summary:

INSP-0131482

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0102031

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0065875

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0065874

Summary:

INSP-0065873

Summary: