summary: Compliance (Initial) - 12/15/2023 - 1/22/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on December 15, 2023, and the off-site documentation review completed on January 22, 2024.


state: AZ

facility_name: HOUSE OF LOVE

summary: Compliance (Annual) - 12/17/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 17, 2025.

inspection_type: Compliance (Annual)

rule: A.R.S. § 36-411.C.1-2. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions 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.

evidence: Based on record review and interview, the owners failed to make documented, good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, one of four personnel members sampled. The deficient practice posed a safety risk as the licensee was unable to verify a person's fitness to work at the facility.

findings: 1. A review of E3's personnel records revealed no documentation of the owners' good faith efforts to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 2. In an interview, E1 reported E1 was unable to locate documentation of good faith efforts to obtain information or recommendations that may be relevant to a person’s fitness to work in a residential care institution within E3’s personnel record. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the health care institution's chief administrative officer failed to ensure each individual who is employed by the health care institution had an assessment of risks of prior exposure to infectious tuberculosis (TB), and determining if the individual had signs or symptoms of tuberculosis for one of three personnel sampled. The deficient practice posed a health and safety risk if a personnel member was not free from infectious TB.

findings: 1. A review of E3's personnel record revealed no documentation of a TB risk assessment or signs and symptoms of TB. 2. In an interview, E1 reported E1 was unable to locate documentation of a TB risk assessment or signs and symptoms of TB within E3’s personnel record. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-703.M.1-3. Administration M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 1. The behavioral health residential facility's current license, 2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and 3. The calendar days and times when a resident may accept visitors or make telephone calls.

evidence: Based on observation and interview, the administrator failed to ensure the location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review were conspicuously posted on the premises. The deficient practice posed a Health and safety risk if residents were unable to verify the facility’s required inspection reports were available.

findings: 1. The Compliance Officer did not observe the behavioral health residential facility's posting with the location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review. 2. In an interview, E1 reported E1 was unaware of the requirement to post inspection reports. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-720.B.4. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a safety risk if employees were unable to implement a disaster plan.

findings: 1. A review of facility documentation revealed documents titled "Disaster Drill Report Form." The documents were dated January 8, 2025 at 10:00 am; June 14, 2025 at 11:40 am. No documentation of a disaster drill for employees conducted on each shift at least once every three months was available for review. 2. In an interview, E1 reported disaster drills were not conducted on each shift at least once every three months. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Compliance (Annual) - 12/9/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 9, 2024:

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(A)(E), for two of four personnel members sampled. The deficient practice posed a risk if E2 and E3 were a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of E2's (hired in 2024) personnel record revealed E2 was hired as a behavioral health technician (BHT). E2's personnel record revealed a documentation of a valid fingerprint clearance card. Additionally, E2's personnel record contained a document titled "ARIZONA DEPARTMENT OF ECONOMIC SECURITY...CRIMINAL HISTORY SELF DISCLOSURE AFFIDAVIT". The document was signed and dated by E2 and a notary, however, the document was from the Arizona Department of Economic Security, and was not from the Bureau of Behavioral Health Licensing, per A.R.S. \'a7 36-425.03(E) 2. A review of E3's (hired in 2024) personnel record revealed E3 was hired as a behavioral health technician (BHT). E2's personnel record revealed a documentation of a valid fingerprint clearance card, and documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 3. A review of the Arizona Department of Public Safety (AZDPS) fingerprint clearance card status request website, conducted on December 9, 2024, revealed E3 had a valid fingerprint clearance card, issued on June 24, 2022. 4. In a joint interview, E1 and E2 acknowledged E2's and E3's documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review, and a copy of E3's valid fingerprint clearance card was not maintained in E3's personnel record.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation and interview, the administrator failed to ensure the premises and equipment were free from a condition or situation which might cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. During an environmental tour of the facility, the Compliance Officer observed at least one hundred instances of bird feces, bird feathers, and one deceased bird on the ground in the back yard area. 2. In an interview, E2 reported the neighborhood had a pigeon infestation due to solar roof panels. 3. In a joint interview, E1 and E2 acknowledged the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.


summary: Initial Monitoring - 4/25/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on April 25, 2024.

inspection_type: Initial Monitoring


summary: Compliance (Initial) - 1/24/2024 - 1/31/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on January 24, 2024, and the off-site documentation review completed on January 31, 2024.

inspection_type: Compliance (Initial)


facility_name: DIVINE HELP LLC

summary: Compliance (Annual) - 11/6/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 6, 2025.

rule: R9-10-109.B.1-2. Changes Affecting a License B. If a licensee intends to terminate the operation of a health care institution , the licensee shall ensure that the Department is notified in writing of: 1. The termination of the health care institution's operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination, and 2. The address and contact information for the location where the health care institution ' s medical records will be retained as required in A.R.S. § 12-2297.

evidence: Based on documentation review, observation, and interview, the licensee failed to ensure the Department was notified in writing of the termination of the health care institution's operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination. The deficient practice posed a risk as the facility was not operating as a health care institution.

findings: A.R.S. §36-401.A.23 states: 'Health care institution' means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. 1. A review of Department documentation revealed a Behavioral Health Residential Facility License (BH9356) was issued on November 29, 2023. 2. The Compliance Officer observed no residents residing at the facility. 3. A review of facility documentation revealed no residents have been admitted to the facility since November 29, 2023. 4. In an interview, E1 reported no residents have been admitted since the facility obtained its license on November 29, 2023. 5. In an exit interview, the findings were reviewed with E1. No additional comments or documents were provided.


summary: Compliance (Annual) - 11/5/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 5, 2024:

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-425.03(A), for two of four personnel members sampled. The deficient practice posed a risk if E3 and E4 were a danger to a vulnerable population.

findings: 1. A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." 2. A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 3. A review of E4's personnel record revealed E4 was hired as a behavioral health professional. E4's personnel record revealed a fingerprint clearance card, however, the card stated "Issue date: 11-01-2018...Expiration Date: 11-01-2024". A review of the Department of the Arizona Department of Public Safety (AZDPS) fingerprint clearance card status website for E4's fingerprint clearance card stated "Status...Not Valid.". Additionally, documentation of compliance with A.R.S. \'a7 36-425.03(E), was not available for review. 4. In a joint interview, E1 and E2 acknowledged documentation of A.R.S. \'a7 36-425.03(E) for E4 was not available for review, and E4's fingerprint clearance card was expired.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan.

findings: 1. A review of Department documentation revealed the perpetual license for BH9356 was effective on November 16, 2023. 2. A review of the daily staffing schedule, dated October 2024. A current schedule was not available for review. The staffing schedule revealed the facility maintained three (3) shifts: -12:00 AM to 8:00 AM; -8:00 AM to 4:00 PM;and -4:00 PM to 12:00 AM. 3. The Compliance Officer requested to review the facility's disaster drills. However, disaster drills were not provided for review. 4. In a joint interview, E1 and E2 reported the facility maintains three shifts. E1 and E2 acknowledged disaster drills for employees were not conducted on each shift at least once every three months.


summary: Change of Service - 7/16/2024 - 7/29/2024

raw_content: No deficiencies were found during the off-site inspection to modify the population from adults to childrens completed on July 29, 2024.

inspection_type: Change of Service


summary: Initial Monitoring - 1/10/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on January 10, 2024.


summary: Compliance (Initial) - 11/8/2023 - 11/16/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 8, 2023, and the off-site documentation review completed on November 16, 2023.


facility_name: NEXUS TEEN ACADEMY LLC

summary: Compliance (Annual) - 5/31/2024

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The director may not accept an accrediation report in lieu of a compliance inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from May 28, 2024 through May 28, 2027. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


summary: Initial Monitoring - 3/14/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on March 14, 2024.


summary: Compliance (Initial) - 12/21/2023 - 1/9/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on December 21, 2023, and the off-site documentation review completed on January 9, 2024.


facility_name: MONTE NIDO ROSEWOOD SCOTTSDALE

summary: Complaint - 7/5/2024

raw_content: An on-site investigation of complaint AZ00203824 was conducted on July 5, 2024, and the following deficiencies were cited :

inspection_type: Complaint

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-425.03(E), for three of four personnel members sampled. The deficient practice posed a risk if E5, E6, and E7 were a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician (BHT). E5's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not available for review. 2. A review of E6's (hired in 2023) personnel record revealed E6 was hired as a BHT. E6's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(A) and A.R.S. \'a7 36-425.03(E), however, the document was not completed within seven working days after employment. 3. A review of E7's (hired in 2023) personnel record revealed E7 was hired as a BHT. E7's personnel record revealed documentation of compliance with A.R.S. \'a7 36-425.03(A) and A.R.S. \'a7 36-425.03(E), however, the document was not completed within seven working days after employment. 4. In a joint interview, E1, E2, and E3 acknowledged E5's personnel record did not contain documentation of compliance with A.R.S. \'a7 36-425.03(E), and documentation of compliance with A.R.S. \'a7 36-425.03(E), was not completed within seven working days after employment for E6 and E7.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and

evidence: Based on documentation review, and interview, the administrator failed to ensure a daily staffing schedule included documentation of the employees who work each calendar day and the hours worked by each employee.

findings: 1. A review of E4's personnel record revealed a document titled "Termination". The document stated "Ineligible due to licensure background. LAST DAY WORKED [date]". 2. A review of facility documentation revealed a staffing schedule dated November 2023. The staffing schedule did not include documentation of the hours worked by E4. 3. In an interview, E8 reported E4 was on-site receiving training on November 27-29, 2024 4. In a joint interview, E1, E2, and E3 acknowledged the daily staffing schedule did not include documentation of the hours worked by E4. .


summary: Initial Monitoring - 11/15/2023

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on November 15, 2023.


summary: Compliance (Initial) - 9/13/2023 - 9/14/2023

raw_content: No deficiencies were found during the on-site initial inspection conducted on September 13, 2023, and the off-site documentation review completed on September 14, 2023.


facility_name: MINDFIT 360

summary: Compliance (Annual) - 9/22/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on September 22, 2025.

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure if a licensee intends to terminate the operation of a health care institution, the licensee shall ensure that the Department is notified in writing of the termination of the health care institution's operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination.

findings: A.R.S. § 36-401A 22 defines a Health care institution means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. Health care institution does not include a community residential setting as defined in section 36-551. 1. A review of Department documentation revealed BH9628 was licensed as a Behavioral Health Residential Facility on September 16, 2024. 2. A request to review resident records revealed no residents had been admitted to BH9628. 3. In an interview, E1 reported the facility had never had residents. E1 acknowledged E1 was not acting as a health care institution due to not having any residents within the last twelve months of maintaining a license.

rule: R9-10-706.K.5. Personnel K. An administrator shall ensure that: 5. A registered nurse is present at the behavioral health residential facility or on-call; and

evidence: Based on documentation review and interview, the administrator failed to ensure a registered nurse was present at the behavioral health residential facility or on-call. The deficient practice posed a risk if a resident were to be admitted and sufficient staff were not hired.

findings: 1. A review of the facility documentation revealed no personnel record for a registered nurse. 2. In an interview, E1 reported the registered nurse terminated their employment due to no residents. E1 acknowledged that the administrator failed to ensure that a registered nurse was present at the behavioral health residential facility or on-call.


summary: Initial Monitoring - 12/16/2024

raw_content: No deficiency was found during the on-site abbreviated follow-up inspection conducted on December 16, 2024.


summary: Compliance (Initial) - 9/12/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on August 26, 2024, and the off-site documentation review completed on September 12, 2024.


facility_name: INTEGRITY YOUTH HOMES LLC

summary: Modification - 8/26/2025

raw_content: No deficiencies were found during the on-site inspection to increase the occupancy, from four to five, conducted on August 26, 2025.

inspection_type: Modification


summary: Complaint - 7/2/2025

raw_content: No deficiencies were found during the on-site investigation of complaint 00135141 conducted on July 2, 2025.


summary: Complaint;Compliance (Annual) - 5/19/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00126015 conducted on May 19, 2025:

inspection_type: Complaint;Compliance (Annual)

evidence: Based on record review and interview, the owners failed to make documented, good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, for two of six personnel members sampled. The deficient practice posed a risk as the licensee was unable to verify a person's fitness to work at the facility.

findings: 1. A review of E3's and E4's personnel records revealed no documentation of the owners' good faith efforts to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 2. In an interview, E1 reported having obtained information and recommendations relevant to E3's and E4's fitness to work in the residential care institution. However, E1 acknowledged those efforts were not documented. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-703.C.1.e.i-iv. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the individual has received cardiopulmonary resuscitation training;

evidence: Based on record review, documentation review, and interview, the administrator failed to document policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, including the method and content of CPR training, to include a demonstration of the individual’s ability to perform CPR. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of personnel members.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "Personnel Qualifications, Duties and Levels." The policy stated, "In addition, all staff must obtain or have current Cardio-Pulmonary Resuscitation (CPR) certification, first aid training and Medication Management Training before providing behavioral health services. These pre-employment requirements will be documented in writing by the Administrator or designee." However, the policy did not cover the method and content of CPR training, including a demonstration of the individual’s ability to perform CPR. 2. A review of E4's (hired in January 2025) personnel record revealed documentation of current cardiopulmonary resuscitation (CPR) training. However, the training was completed online and did not include a demonstration of the individual’s ability to perform CPR. 3. In an interview, E1 acknowledged E4’s CPR training did not include a demonstration of E4’s ability to perform CPR. 4. A review of E6’s (hired in April 2024) personnel record revealed documentation of current CPR training. However, the training was completed online and did not include a demonstration of the E6’s ability to perform CPR. 5. In an interview, E1 acknowledged E6’s CPR training did not include a demonstration of E6’s ability to perform CPR. 6. In an exit interview, the findings were discussed with E1, and no further statements or documentation were provided.

rule: R9-10-706.G.3.a. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for two of six personnel members sampled.

findings: 1. A review of E3's and E4's personnel records revealed no documentation of the individuals' qualifications, including skills and knowledge applicable to the individual's job duties. 2. A review of the facility's undated policies and procedures revealed a policy titled "Qualifications, Skills and Knowledge Verification Policy and Procedure (QSK)." The policy stated, "We will commit to confirming and verifying the QSK (Qualifications, Skills & Knowledge) through the following methods: Speaking with references (which will be notated under the notes section of the new hire/contractor checklist)." 3. In an interview, E1 reported having verified E3's and E4's skills and knowledge. However, E1 acknowledged the verifications were not documented. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-707.A.10.b. Admission; Assessment A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident's current admission: b. The review and update of the resident's assessment information is documented in the resident's medical record within 48 hours after the review is completed;

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment received from a behavioral health provider, completed within 12 months before the date of the resident's current admission, was reviewed and updated and the assessment was documented in the medical record within 48 hours after the review was completed, for two of two residents sampled.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a behavioral health assessment (dated in November 2024), received from R1's former behavioral health provider. The assessment was dated within twelve months prior to R1's admission. The documentation met the criteria in R9-10-708.A.8. However, no documentation to indicate this assessment information was reviewed and updated by E6 within 48 hours after the review was available for review. 2. A review of R2's (admitted in 2025) medical record revealed a behavioral health assessment (dated in March 2025), received from R2’s former behavioral health provider. The assessment was dated within twelve months prior to R2's admission. The assessment met the criteria in R9-10-708.A.8. However, no documentation to indicate this assessment information was reviewed and updated by E6 within 48 hours after the review was completed was available for review. 3. A review of R1's medical record revealed a progress note dated in April 2025. The note stated, “…[R1] had group therapy with no issues.” 4. A review of R2's medical record revealed a progress note dated in May 2025. The note stated “…[R2] then participated in group therapy facilitated by staff…” 5. In a joint interview, E2 acknowledged the behavioral health assessments conducted prior to R1's and R2's admission were not reviewed and updated within 48 hours.

rule: R9-10-716.C.2.b. Behavioral Health Services C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: b. The amount of time spent in the counseling session;

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include the amount of time spent in the counseling session, for two of two residents sampled. The deficient practice posed a risk if the residents did not receive treatment to cure, improve, or palliate the residents' behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed counseling notes dated in April-May 2025. However, each counseling session was not documented to include the amount of time spent in the counseling sessions. 2. A review of R2's medical record revealed counseling notes dated in May 2025. However, each counseling session was not documented to include the amount of time spent in the counseling session. 3. In an interview, E2 acknowledged the documented counseling sessions did not include the amount of time spent in each counseling session. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-716.C.2.c. Behavioral Health Services C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: c. Whether the counseling was individual counseling, family counseling, or group counseling;

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include whether the counseling was individual counseling or group counseling, for two of two residents sampled. The deficient practice posed a risk if the residents did not receive treatment to cure, improve, or palliate the residents' behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed counseling notes dated in April-May 2025. However, each counseling session was not documented to include whether the counseling was individual counseling or group counseling. 2.A review of R2's medical record revealed counseling notes dated in May 2025. However, each counseling session was not documented to include whether the counseling was individual counseling or group counseling. 3. In an interview, E2 reported R1 and R2 received both individual and group counseling. E2 acknowledged the documented counseling sessions did not include whether the counseling was individual counseling or group counseling. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-716.C.2.d. Behavioral Health Services C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: d. The treatment goals addressed in the counseling session; and

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include the treatment goals addressed in the counseling session, for two of two residents sampled. The deficient practice posed a risk if the residents did not receive treatment to cure, improve, or palliate the residents' behavioral health issues at the health care institution.

findings: 1. A review of R1's medical record revealed counseling notes dated in April-May 2025. However, each counseling session was not documented to include the treatment goals addressed in the counseling session. 2. A review of R2's medical record revealed counseling notes dated in May 2025. However, each counseling session was not documented to include the treatment goals addressed in the counseling sessions. 3. In an interview, E2 acknowledged the documented counseling sessions did not include the treatment goals addressed in the counseling sessions. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-716.C.2.e. Behavioral Health Services C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: e. The signature of the personnel member who provided the counseling and the date signed.

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include the signature of the personnel member who provided the counseling and the date signed, for two of two residents sampled. The deficient practice posed a risk if the residents did not receive treatment to cure, improve, or palliate the residents' behavioral health issues at the health care institution.

findings: 1. A review of R1's medical record revealed counseling notes dated in April-May 2025. However, each counseling session was not documented to include the signature of the personnel member who provided the counseling and the date signed. 2. A review of R2's medical record revealed counseling notes dated in May 2025. However, each counseling session was not documented to include the signature of the personnel member who provided the counseling and the date signed. 3. In an interview, E2 reported R1 and R2 participated in counseling sessions conducted by behavioral health technicians and a behavioral health professional. E2 acknowledged the documented counseling sessions did not include the signature of the personnel member who provided the counseling and the date signed. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.


summary: Initial Monitoring - 8/5/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on August 5, 2024.


summary: Compliance (Initial) - 3/19/2024 - 6/11/2024

raw_content: No deficiencies were found during the on-site initial inspections conducted on March 19, 2024 and May 30, 2024; and the off-site documentation review completed on June 11, 2024.


facility_name: SUNNY SIDE GROUP HOME

summary: Compliance (Annual) - 8/18/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on August 18, 2025:

evidence: Based on documentation review, observation, record review, and interview, the licensee failed to ensure the Department was notified in writing of the termination of the health care institution's operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination. The deficient practice posed a risk as the facility was not operating as a health care institution, and the condition of the facility posed a risk to the health and safety of an individual.

findings: A.R.S. § 36-401(23) "Health care institution" means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. A review of Department documentation revealed the following substantive policy statement effective August 23, 2021: "The purpose of this substantive policy statement is to notify the public of the Department's interpretation of the definition of 'health care institution,' contained in A.R.S. § 36-401, as it relates to a health care institution license under A.R.S. § 36-424 and 36-425. A.R.S. §36-401 states: 'Health care institution' means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies. The Department interprets this definition to mean that in order to be a health care institution, a place, institution, building, or agency must be providing medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services, or directed care services. A place, institution, building, or agency that does not provide any of these services for an extended period of time ceases to be a health care institution, because it no longer fits within the statutory definition of 'health care institution'. If the Department determines upon performing a compliance inspection for a health care institution that a licensed 'health care institution' has not provided medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services, or directed care services for 12 consecutive months, the Department shall revoke the health care institution license on the grounds that the place, institution, building, or agency is not a health care institution and thus is ineligible for licensure." A review of Department documentation revealed the behavioral health residential facility perpetual license (BH9801) was effective on July 31, 2024. The Compliance Officers observed a license conspicuously posted on the premises for BH9801, dated July 31, 2024, with an anniversary date of July 30, 2025. The Compliance Officers observed no residents on the premises. The Compliance Officers observed a toilet with low water and discoloration in the toilet bowl. In an interview, E1 reported E1 had the water turned off because there were no residents and no services were being provided. A review of Department documentation revealed an email received by the Department on May 30, 2025 from E2. The email revealed E2 ended E2’s contract as the behavioral health professional (BHP) with BH9801. In an interview, E1 reported BH9801 did not have a BHP. E1 reported E1 was in the process of signing a contract with O1. In an interview, E1 reported no residents had been admitted to the facility since the facility was licensed. E1 reported the facility had not yet accepted residents due to the Arizona Health Care Contract Containment System (AHCCCS) moratorium. E1 reported the facility recently received a contract with AHCCCS. In an interview, E1 reported the facility was working with the Arizona Department of Child Safety, Arizona Department of Economic Security, and the Salt River Pima–Maricopa Indian Community for referrals and placement. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.


summary: Initial Monitoring - 10/8/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on October 08, 2024.


summary: Compliance (Initial) - 7/11/2024 - 7/26/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on July 11, 2024 and the off-site documentation review completed on July 26, 2024.


facility_name: INNERG HOMES

summary: Compliance (Annual) - 10/3/2025

raw_content: No deficiencies were found during the attempted on-site inspection on October 3, 2025, and the on-site compliance inspection conducted on October 3, 2025.


summary: Initial Monitoring - 10/11/2024

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on October 11, 2024:

rule: A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of one resident sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

findings: 1. A review of R1's medical record did not reveal a nursing assessment or medical history and physical examination dated within 30 calendar days before admission or within 72 hours after admission. 2. In an interview, E1 acknowledged R1's nursing assessment or medical history and physical examinations was not available for review. R1 reported R1 had to request the record from a provider.

rule: A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

evidence: Based on record review and interview, the administrator failed to ensure, if a behavioral health assessment was conducted by a behavioral health technician (BHT) or registered nurse, within 24 hours a behavioral health professional (BHP), certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure that the behavioral health assessment identified the behavioral health services needed by the resident, for one of one resident sampled.

findings: 1. A review of R1's medical record revealed a document titled, "Student Intake," dated September, 2024. At the time of the inspection it was unknown which personnel conducted the assessment and the assessment did not include a signature of the behavioral health professional who reviewed the behavioral health assessment. 2. In an interview, E1 acknowledged R1's behavioral health assessment was not reviewed and signed by a behavioral health professional to ensure the behavioral health assessment identified the behavioral health services needed by R1.

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: b. Includes: iii. The signature and date signed of the personnel member conducting the behavioral health assessment; and

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment included the signature and date signed by the personnel member conducting the behavioral health assessment, for one of one resident sampled. The deficient practice posed a risk if the Department was unable to determine if an assessment had been completed and in accordance with R9-10-707.A.11.b.iii.

findings: 1. A review of R1's medical record revealed a behavioral health assessment dated September 23, 2024. However, the document was not signed or dated by the personnel member conducting the behavioral health assessment. 2. In an interview, E1 acknowledged R1's behavioral health assessment did not include the signature and date signed by the personnel member who conducted the behavioral health assessment.

rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and b. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission, for one of one resident sampled. The deficient practice posed risk to infection control.

findings: 1. A review of R1's medical record (admitted September, 2024) did not reveal documentation of R1's freedom from infectious TB. 2. In an interview, E1 acknowledged R1's medical record did not contain documentation of freedom from infectious TB. E1 stated E1 would have to request the document from a provider.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 2. Is completed: b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was completed, before physical health or behavioral health services were provided, or within 48 hours after the assessment is completed for one of one resident sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R1's medical record revealed an intake assessment dated September 23, 2024. R1's medical record revealed a treatment plan dated September 27, 2024. The treatment plan was not completed within 48 hours after the assessment was completed and as per R9-10-708.A.2.b. 2. In an interview, E1 acknowledged a treatment plan for R1 was not completed within 48 hours after the assessment was completed and as per R9-10-708.A.2.b.


summary: Compliance (Initial) - 5/21/2024 - 6/19/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on May 21, 2024 and the off-site documentation review completed on June 19, 2024.


facility_name: THY GRACE CARE 2

summary: Compliance (Annual) - 6/16/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on June 16, 2025.


summary: Complaint - 11/18/2024

raw_content: An on-site investigation of complaint AZ00218777 was conducted on November 18, 2024 and no deficiencies were cited.


summary: Initial Monitoring - 7/16/2024

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on July 16, 2024.


summary: Compliance (Initial) - 5/10/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on May 10, 2024.


state: WA

facility_name: Daybreak Youth Services – Brush Prairie

summary: State Inspection


facility_name: Daybreak Youth Services – Spokane Inpatient

report_date: December 30, 2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-3888, 2020-3890
License Number: RTF.FS.00001010, BHA.FS.60873305
Date(s) of Investigation: 03/10/20-12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympic Washington 98504-7874


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-4616, 2020-4617
License Number: BHA.FS.60873305, RTF.FS.00001010
Date(s) of Investigation: 04/13/20 - 12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 30, 2020
Daybreak Youth Services - Spokane
628 S Cowley St
Spokane,WA 99202-1377
Re: Complaint Investigation
Case Number: 2020-4631, 2020-4632
License Number: RTF.FS.00001010, BHA.FS.60873305
Date(s) of Investigation: 04/13/20-12/29/20
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Spokane on December 29, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: #33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


facility_name: Newport Academy

report_date: February 21, 2025

summary: State Inspection — ONGOING - ROUTINE (01/29/25)

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
February 21, 2025
Newport Academy, 3804 Hastings Ave W, Port Townsend, WA. 98368-9642 Michael Tyers
Agency Name and Address Administrator
ONGOING - ROUTINE 01/29/25 ECR03
Inspection Type Inspection Onsite Dates Inspector
X2025-66 RTF.FS.60957241 Co-occurring Services
Inspection Number License Number RTF Services Types
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
During the inspection the following complaints were reviewed: 2025-240.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0780 Management of human resources Based on interview, policy and procedure review, and 0780 Management of human
WAC 246-337-050(7)(d) (7) The licensee shall personnel record review, the agency failed to ensure resources
have written documentation for each staff all staff had a signed position description in the WAC 246-337-050(7)(d)
member including: (d) Current signed job personnel records. Deficiency will be corrected as
description. followed: Human Resources is
Failure to ensure a signed position description in the responsible for implementing this
personnel file can lead to missed staff correction. Effective 3/3/2025,
responsibilities and can lead to client harm. Human Resources has confirmed
signed position description in
Findings included: staff personnel files. Human
Resources will complete monthly
audit reports to ensure all new
and current employees have
1. Review of the personnel records for Staff G, Care signed position descriptions in
Coordinator, showed that there was no signed staff files.
position description in their personnel file.
2. During an interview with Staff I, Human Resources
(HR) Generalist, on 01/29/25 at 01:00 PM, they
stated, “It looks like we do not have a signed position
description.”
3. Review of the policies and procedures titled,
“Agency Personnel Record Requirements”, updated
11/01/23, states the agency will maintain a current,
signed job description for all staff.
0790 Management of human resources Based on interview, policy and procedure review, and 0790 Management of human
WAC 246-337-050(7)(f) (7) The licensee shall personnel record review, the agency failed to ensure resources
have written documentation for each staff all staff had a copy of their current credential in the WAC 246-337-050(7)(f)
member including: (f) Current license, personnel records. Deficiency will be corrected as
certification, or registration, if applicable. followed: Human Resources is
Failure to ensure staff are credentialed may lead to responsible for implementing this
poor client outcomes. correction. Effective 3/3/2025,
Human Resources has confirmed
Findings included: all new and current clinical team
members have current
1. Review of the personnel records for Staff D, credentials in personnel files.
Clinical Director, showed there was no record of a Human Resources will complete
current credential in the personnel record. monthly audit reports to ensure
2. During an interview with Staff I, Human Resources all new and current clinical team
(HR) Generalist, on 01/29/25 at 01:00 PM, they members have current
verified there was no record of a current credential in credentials in staff personnel
the personnel record and stated, “I am not seeing his files.
most current one in the file.”
3. Review of the policies and procedures titled,
“Agency Personnel Record Requirements”, updated
11/01/23, states the personnel record must have a
copy of the staff member's valid current credential
issued by the department if they provide clinical
services.
0805 Management of human resources Based on interview and personnel record review, the 0805 Management of human
WAC 246-337-050(7)(i) (7) The licensee shall agency failed to ensure all appropriate staff had resources
have written documentation for each staff current driver’s licenses. WAC 246-337-050(7)(i) Deficiency
member including: (i) Current driver's license, will be corrected as followed:
if applicable. Failure to ensure a current driver’s license may result Human resources is responsible
in unauthorized staff transporting clients. for implementing this correction.
Human Resources will ensure
Findings included: that all new and current employee
files have a copy of the current
1. Review of the personnel records for Staff D, Clinical Driver’s License effective
Director, Staff G, Care Coordinator, and Staff H, 2/11/2025. Human Resources will
Experiential Therapist, showed they did not have a current enter all Driver’s License data into
driver’s license in the personnel file.
employee files where a monthly
2. During an interview with Staff I, Human Resources (HR)
audit report will be generated.
Generalist, on 01/29/25 at 01:00 PM, they verified
This will ensure monthly auditing
there was no record of a current driver’s license in the
of soon to be expired Driver’s
personnel record.
Licenses and prompt staff to
provide up to date information.
2980 Water supply, sewage and waste Based on interview and inspection of the facility, the 2980 Water supply, sewage and
disposal agency failed to maintain hot water temperatures waste disposal
WAC 246-337-130(2) The licensee shall between 100 and 120-degrees Fahrenheit throughout WAC 246-337-130(2) Deficiency
ensure: (2) Tempered water between one the facility. will be corrected as followed:
hundred and one hundred twenty degrees Facilities Manager is responsible
Fahrenheit in resident areas. Failure to provide proper water temperatures may for implementing this correction.
result in disease transmission for staff and clients. As of 3/3/2025, setting on the hot
water heater has been increased.
Findings included: Hemlock shower currently
reading 104.2 degrees. Facilities
1. During the inspection of the facility, the Reviewer Manager will re-test water
observed that the hot water temperatures did not temperature every two weeks
meet the correct water temperature as evidenced by over the next 30 days and make
the following: additional adjustments as
a. The temperature of Hemlock’s shower was 80.2 needed. Facilities Manager will
degrees F. consider adding pipe insulation if
water temperature drops.
2. During an interview with Staff C, Compliance
Specialist, on 01/29/25 at 11:00 AM, they verified the
below standard water temperature.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
You are required to respond to the Inspection Report with Noted Deficiencies by submitting a plan of correction (POC). Be sure to refer to
the deficiency number. If you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected
and/or in compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction
must include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the
deficiency. Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to
accomplish total correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to
accomplish correction; the target completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the
correction of the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page
number to which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection
report you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
3/19/2025
Newport Academy
3804 Hastings Ave W
Port Townsend, WA 98368-9642
Re: Exam Number: X2025-66
License Number: RTF.FS.60957241
Approved Plan of Correction
Date(s) of Inspection: 01/29/25
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer: ECR03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874

report_type: Inspection Report

inspection_type: ONGOING - ROUTINE

administrator: Michael Tyers

service_types: Co-occurring Services


summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
No Deficiencies Found
June 16, 2023
Michael Tyers
Newport Academy
19200 Von Karman Ave Ste 500
Irvine, CA 92612-8513
Subject: Inspection Number: X2023-112
License Number: RTF.FS.60957241
Inspection Type: ONGOING - ROUTINE
Dear Mr. Michael Tyers
This document contains information regarding the recent inspection of Newport Academy, 3804
Hastings Ave W, Port Townsend, WA. 98368-9642 by the Washington State Department of Health.
Your state licensing inspection was completed on 06/08/2023.
During the inspection, no deficient practice was found.
Please contact me if there are questions regarding the inspection process. I may be reached at (360)
236-2324. I am also available by email at Rosa.Elvia@doh.wa.gov.
I want to extend another “thank you” to you and to everyone that assisted me during the survey.
Sincerely,
Rosa Elvia SUDP
Facility Inspector


report_date: October 12, 2022

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
October 12, 2022
Crystal Goodwin
Michael Tyers
Zachary Thompson
3084 Hastings Avenue West
Port Townsend, WA 98368
Dear Administration:
This letter contains information regarding the recent investigation of Newport Academy by the
State of Washington Department of Health which was conducted on September 12, 2022.
No deficient practices were identified during the investigation for 2022-10157 and no citation
will be issued.
Please retain a copy of this letter for your files. If you have any questions, please contact me at
the email you have on file.
I wish to thank you and your staff for the assistance provided during the investigation process.
Sincerely,
Behavioral Health Investigator 42124
Health Services Consultant 4
Health Systems Quality Assurance Division
Washington State Department of Health


summary: State Investigation

raw_content:
Statement of Deficiency Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
Newport Academy 3804 Hastings Avenue West Port Townsend, WA
98368 Crystal Goodwin
Agency Name and Address Administrator
Investigation Tuesday, April 12, 2022 42124
Inspection Type Investigation Start Date Investigator Number
2022-3097 RTF.FS.60957241 RTF inpatient
Case Number License Number BHA/RTF Agency Services Type
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the investigation.
Deficiency Number and Rule Reference Findings Plan of Correction
WAC 246-337-075 (2)(a)(g) Resident rights. The Based on staff interview, root cause analysis review, As noted in the RCA, Interim
licensee must establish a process to ensure policy and procedure review, and patient clinical Executive Director, Kristina
resident rights are protected in compliance with document review, the agency failed to ensure patients Schemnitzer, implemented the
chapter 71.12 RCW, this chapter, and other were free from abuse and failed to ensure they had a following
applicable laws, and are based on the service safe environment for 4 of 4 patients reviewed (Patient • Daily safety walkthroughs
types provided in the RTF. This process must #1, #2, #3, and #4). which included
address how the RTF will: (2) Treat each resident environmental safety checks
in a manner that respects individual identity, Failure to ensure patients are free from abuse and have as well as an increased
human dignity and fosters constructive self- a safe environment can lead to poor patient outcomes supervision beginning
esteem. Each resident has the right to: (a) Be and create long term traumas. 3/4/22
free of abuse, including being deprived of food,
Findings included:
clothes or other basic necessities; (g) Have a safe 1. During an interview on 04/12/22 at 1:00 PM, Staff A, • Ongoing live, in the moment
and clean environment. Licensing and Compliance Manager, stated that patients coaching and training for all
“are supervised at all times…we do regular checks.” Staff staff
A stated that the patients supervised at all times means • Sent out program-wide
that they are within eyesight- but not line of sight or one email about safety and
to one. Staff A stated that, “they just can’t roam around supervision
campus and do whatever they want.” Staff A stated that • Local Leadership
there are 15-minute checks at night. implemented culture of
accountability around client
2. Review of the document titled, "Facility Rules & supervision
Guidelines", undated, showed that facility rules included • Training on supervision
the following: "Residents are not allowed in other completed with all staff in 2
resident's bedrooms at any time; residents must be in meetings on 3/31/22
their own bedroom at the designated 'lights out' time; • Increased frequency of
residents may be asked to leave bedroom door ajar…" accountability feedback and
During an email exchange between the Investigator and
disciplinary action for those
Staff A on 04/28/22 at 9:53 AM, Staff A stated that these staff who do not follow
rules were provided to all patients in the handbook
supervision protocols
upon admission.
• Hired additional staff to
have available in the event
3. Review of the “Root Cause Analysis”, dated 03/07/22,
of staffing shortages on
showed that Patient #3 had gone into the room of
shifts/call offs
Patient #1, #2 and #4 on the night of the alleged sexual
assault incident. Incident documentation showed the
patients stated that the case manager "was lenient and
allowed clients to be in each other's bedrooms."
4. Review of the “Root Cause Analysis” document
showed that Patient #3 reported that “2 peers held
[them] down and a 3rd peer rubbed [their] private parts
on [their] face”. The patient stated they called for help
but felt like no one could hear [them].
5. Review of the “Root Cause Analysis” document
showed that Patients #1, #2, and #4, were interviewed.
Patient #2 denied everything; it was discovered through
patient interviews that Patient #1 and #4 held Patient #3
down while Patient #2 rubbed their genitals on Patient
#3's face.
6. Review of the section in the “Root Cause Analysis”
titled, "Analysis" showed that the “policy for supervision
of the patients was not followed”, and staff were
permitting patients to be in one another's rooms.
WAC 246-337-075 (3) Resident rights. The Based on staff interview and policy and procedure Upon investigation, it was
licensee must establish a process to ensure review, the agency failed to provide patient rights to 1 determined that Patient #3 refused
resident rights are protected in compliance with of 4 patients reviewed (Patient #3). to sign consents. This was verbally
chapter 71.12 RCW, this chapter, and other confirmed by Residential Supervisor
applicable laws, and are based on the service Failure to ensure that patient rights are provided upon
types provided in the RTF. This process must admission can lead to poor patient outcomes. Compliance Manager, Crystal
address how the RTF will: (3) On or before Goodwin, completed training with
admission, document that each resident, or the Findings included: all Residential Supervisors on
resident’s personal representative, designee, 5/25/22 covering consent process
parent or guardian receives a written copy of the 1. Review of the policy titled, "Individual Rights", revised during the admission process. We
resident’s rights that includes all items in 01/01/21, showed that the patient rights would be discussed the process for
subsection (2) of this section. posted in a central location and would be reviewed with generating consents, protocols and
all patients upon admission. The procedure showed that timelines, how to document when a
all patients and parents or guardians are provided a client refuses to sign consents and
copy of the rights upon admission. any additional questions.
2. During an email exchange between the Investigator
and Staff A, Licensing and Compliance Manager, on
04/25/22 at 5:16 PM, Staff A stated they were unable to
locate signed patient rights for Patient #3.
WAC 246-337-065 (5)(a) Safety and Security. The Based on staff interview, the agency failed to report to Compliance Manager, Crystal
licensee must protect resident safety and the Department of Health an incident of sexual abuse Goodwin, completed training with
security by developing written policies and for 1 or 4 patients reviewed (Patient #3). newly onboarded Executive
procedures that are consistent with the Director, Interim Executive Director
requirements of this chapter and address: (5) Failure to report incidents of abuse to the department and Residential Manager on
Reporting to the department and other within the reporting times can result in poor patient reporting requirements in line with
appropriate agencies, by the end of the next outcomes. WAC 246-337-065. Moving forward,
business day of the incident occurring, serious or the Executive Director will be
undesirable outcomes that occur in the facility Findings included: responsible for reporting any
including: (a) Allegations of abuse. instances of abuse to the
1. During an interview on 04/12/22 at 1:00 PM, Staff A, Department of Health.
Licensing and Compliance Manager, stated that the
alleged sexual assault incident was only reported to the
Department of Children, Youth and Family (DCYF) and
was not reported to DOH. Staff A was not aware that
this should have been reported to the Department of
Health.
Plan of Correction Instructions
Introduction
We require that you submit a plan of correction for each deficiency listed on the statement of deficiency form. Your plan of correction must be
Submitted to DOH within fourteen calendar days of receipt of the list of deficiencies.
You are required to respond to the statement of deficiencies by submitting a plan of correction (POC). Be sure to refer to the deficiency number. If
you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies, you will be sent a letter
detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification or have questions about deficiencies, you must contact the investigator who
conducted the investigation.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
May 25, 2022
Newport Academy
3804 Hastings Ave. West
Port Townsend, WA 98368
Re: Case Number: 2022-3097 RTF
License Number: BHA.FS.60957241
Acceptable Plan of Correction
Date of Survey: April 12, 2022
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the investigation recently conducted at your facility, the Department has
determined that the POC is acceptable. You stated in your plan that you will implement
corrective actions by the specified timeline. By this, the Department is accepting your Plan of
Correction as your confirmation of compliance.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an unannounced follow-up compliance visit to verify that all
deficiencies have been corrected. Any fees that may be enforced based on the results of the
investigation will be implemented consistent with WAC 246-341-0365 and WAC 246-337-990
In addition, the Department reserves the right to pursue enforcement action for any repeat and/or
uncorrected deficiencies based on applicable statute and rules.
Please feel free to contact me at the email address you have on file if you have questions
regarding the investigation.
The survey team sincerely appreciates your cooperation and hard work during the investigation.
Sincerely,
Investigator 42124
Behavioral Health Investigator
Health Services Consultant 4

report_type: Report

administrator: Crystal Goodwin


summary: State Investigation

deficiencies: WAC 246-337-080 Resident care services. At Newport Academy Port Townsend/ if a Nurse is not available for a med pass shift/ CC staff will participate in medication observation. The RN nurse manager is available by phone 24 hours a day/ 7 days a week at this location if any issues arise on site. In response to Citation in reference of: WAC 246-337-105 Medication management. In the absence of Nursing staffing during medication pass, trained CC staff will do medication observation.


facility_name: Newport Academy - Seattle

report_date: January 31, 2025

summary: State Inspection — ONGOING - ROUTINE (12/03/24)

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
January 31, 2025
Newport Academy - Seattle, 12029 113th Ave NE, Kirkland, WA. 98034-6901 David Laxton
Agency Name and Address Administrator
ONGOING - ROUTINE 12/03/24 ECR03
Inspection Type Inspection Onsite Dates Inspector
X2024-957 RTF.FS.61015924 Co-occurring Services
Inspection Number License Number RTF Services Types
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0615 Management of human resources Based on interview and personnel record review, the 0615 Management of human
WAC 246-337-050(4) (4) Staff must be trained, agency failed to ensure all staff had initial violence resources
authorized, and where applicable credentialed prevention training in the personnel record. WAC 246-337-050(4) Deficiency
to perform assigned job responsibilities will be corrected as followed:
consistent with scopes of practice, resident Failure to ensure timely training may result in client Human Resources will perform
population characteristics and the resident's harm. monthly audits on staff initial
individual service plan. violence prevention trainings in
Findings included: the personnel record and provide
1. Review of the personnel record for Staff A, Mental findings to Residential Leadership
Health Clinical Supervisor, and Staff B, Team (Program Manager,
Administrative Assistant, showed that there was no Executive Director, Clinical
initial violence prevention training in their personnel Director). All initial violence
file. prevention trainings are
completed within the first 30 days
for all new hires. Initial violence
2. During an interview with Staff E, Human Resources prevention trainings are
(HR) Generalist, on 12/03/24 at 12:58 PM, they conducted twice a month. Please
stated, “I don’t see one in their first 90 days.” see attached Policy.
0620 Management of human resources Based on interview and personnel record review, the 0620 Management of human
WAC 246-337-050(5)(a) (5) The licensee must agency failed to ensure all staff had ongoing training resources
document that staff receive the following in the personnel record. WAC 246-337-050(5)(a)
training as applicable: (a) Initial orientation Deficiency has been corrected as
and ongoing training to address the safety and Failure to ensure ongoing training may result in client followed:
health care needs of the residents served for harm. Cultural Competency Trainings
all staff. have been identified in staff files
Findings included: and titled “Implicit Bias.”
1. Review of the personnel record for Staff B, Transcripts for Staff B have been
Administrative Assistant, showed that there were no attached for confirmation of
annual cultural competency trainings in their cultural competency training in
personnel file. personnel file. Human Resources
2. During an interview with Staff E, HR Generalist, on has been educated on training
12/03/24 at 11:45 AM, they stated, “I don’t see any modules titles and their contents.
cultural competency trainings in the file.” In July 2024, the organization
switched to Relias Training
Program and implemented an
Education Fair in which all
required annual trainings are
automatically assigned to all
staff.
0805 Management of human resources Based on interview and personnel record review, the 0805 Management of human
WAC 246-337-050(7)(i) (7) The licensee shall agency failed to ensure all staff had a current driver’s resources
have written documentation for each staff license in the personnel record. WAC 246-337-050(7)(i)
member including: (i) Current driver's license, Deficiency will be corrected as
if applicable. Failure to ensure a current driver’s license in the followed:
personnel file can lead to missed staff Human resources is responsible
responsibilities and result in client harm. for implementing this correction.
Human Resources will ensure
Findings included: that all new and current employee
1. Review of the personnel record for Staff B, files have a copy of the current
Administrative Assistant, showed that there was no Driver’s License effective
current driver’s license in their personnel file. 2/11/2025. Human Resources will
2. During an interview with Staff E, HR Generalist, on enter all Driver’s License data into
12/03/24 at 12:52 PM, they stated, “I don’t have that.” employee files where a monthly
audit report will be generated.
This will ensure monthly auditing
of soon to be expired Driver’s
Licenses and prompt staff to
provide up to date information.
0810 Management of human resources Based on interview and personnel record review, the 0810 Management of human
WAC 246-337-050(7)(j) (7) The licensee shall agency failed to ensure all staff had an initial and resources
have written documentation for each staff ongoing tuberculosis screening in the personnel file. WAC 246-337-050(7)(j)
member including: (j) Initial and ongoing Deficiency will be corrected as
tuberculosis screening according to the facility Failure to ensure staff had an initial and ongoing followed:
risk assessment and tuberculosis written plan tuberculosis screening may result in staff/client Human Resources is responsible
according to WAC 246-337-060. harm. for implementing this correction.
Effective 2/11/2025, Human
Findings included: Resources has confirmed initial
1. Review of the personnel record for Staff B, and ongoing Tuberculosis
Administrative Assistant, showed that there was no screening in staff personnel files.
tuberculosis screening in their personnel file. Human Resources will complete
2. During an interview with Staff E, HR Generalist, on monthly audit reports to ensure
12/03/24 at 12:55 PM, they stated, “It is not in the all new and current employees
file.” have completed and added initial
and ongoing Tuberculosis
screenings to staff files.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
You are required to respond to the Inspection Report with Noted Deficiencies by submitting a plan of correction (POC). Be sure to refer to
the deficiency number. If you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected
and/or in compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction
must include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the
deficiency. Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to
accomplish total correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to
accomplish correction; the target completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the
correction of the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page
number to which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection
report you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
2/18/2025
Newport Academy - Seattle
12029 113th Ave NE
Kirkland, WA 98034-6901
Re: Exam Number: X2024-957
License Number: RTF.FS.61015924
Approved Plan of Correction
Date(s) of Inspection: 12/03/24
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer: ECR03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874

administrator: David Laxton


report_date: October 17, 2023

summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874  Olympia, Washington 98504-7874
No Deficiencies Found
October 17, 2023
David Laxton
Newport Academy - Seattle
19200 Von Karman Ave Ste 500
Irvine, CA 92612-8513
Subject: Inspection Number: X2023-253
License Number: RTF.FS.61015924
Inspection Type: ONGOING - ROUTINE
Dear Mr. David Laxton
This document contains information regarding the recent inspection of Newport Academy - Seattle,
12029 113th Ave NE, Kirkland, WA. 98034-6901 by the Washington State Department of Health.
Your state licensing inspection was completed on 04/21/2023.
During the inspection, no deficient practice was found.
Please contact me if there are questions regarding the inspection process. I may be reached at (360)
236-4690.
I want to extend another “thank you” to you and to everyone that assisted me during the survey.
Sincerely,
JRM43
Facility Inspector