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Page 1: 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):

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Page 2: 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):

Residential Care Services Investigation Summary Report

Provider/Facility: AWA and Malick Adult Family HomeLLC (1133622)

Intake ID(s): 3596436

License/Cert. #: AF753767Investigator: Wylie, Megan Region/Unit: RCS Region 2/Unit B Investigation

Date(s):01/08/201901/18/2019

through

Complainant Contact Date(s):Allegations:A named resident left the home and failed to return when expected. When the resident did return he had a wound on the face.

Investigation Methods:Sample: Named Resident, 1

unnamed resident, 2 staffObservations: Staff to resident

interactions,environment, care andservices, meals, residentto resident interactions

Interviews: Named resident, 2unnamed residents,Provider and 2caregivers, family.

Record Reviews: Named resident,unnamed resident,Provider, 2 Caregivers,Incident log, incidentinvestigation.

Allegation Summary:A named resident failed to return to the home when expected. When the resident did come home there was a wound on theresident's nose. The Provider made the appropriate notifications in a timely manner. The named resident's negotiated care plandid not address the named residents behaviors including the elopements.

Unalleged Violation(s):This investigation was done with the full inspection dated 01/08/19

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

388-76-10355 (7)(a)(b)(c) - Negotiated Care Plan to include behaviors and interventions to reduce tension, agitation and problembehaviors.

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Page 3: 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):

Residential Care Services Investigation Summary Report

Provider/Facility: AWA and Malick Adult Family HomeLLC (1133622)

Intake ID(s): 3603898

License/Cert. #: AF753767Investigator: Wylie, Megan Region/Unit: RCS Region 2/Unit B Investigation

Date(s):01/08/201901/18/2019

through

Complainant Contact Date(s):Allegations:A named resident left the home and failed to return when expected.

Investigation Methods:Sample: Named resident, 1

unnamed resident, 2 staffObservations: staff to resident

interactions, resident toresident interactions,environment, meals, careand services

Interviews: Named resident, Namedresident's representative,Provider, 2 caregivers.

Record Reviews: Named Resident,unnamed resident,provider, 2 caregivers,incident log, incidentinvestigation.

Allegation Summary:A named resident failed to return to the home when expected. The resident returned home and the Provider made theappropriate notifications, but failed to update the Negotiated Care Plan to include interventions and safety measures.

Unalleged Violation(s):This investigation was completed with the full inspection dated 01/08/19

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

388-76-10355 (7)(a)(b)(c) - Negotiated Care Plan to include behaviors and interventions to reduce tension, agitation and problembehaviors.

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Page 5: 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):

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Page 6: 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):

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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

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 ] 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 · 2019. 10. 29. · 1) the ALF acted immediately to evaluate the resident after the fall, call ed911 for further evaluation and transportation

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Unalleged Violation(s): 1: The named resident's negotiated care plan was not signed. 2: The named resident did not have an updated

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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

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

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Plan of Correction Page 9 of 10 License #: 2229 CHATEAU PACIFIC RETIREMENT COMMUNITY Licensee: CP RETIREMENT LLC Completion Date

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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