summary: Complaint - 2/26/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00160179 conducted on February 26, 2026.

rule: R9-10-703.K.9. Administration K. An administrator shall: 9. Evaluate and take action related to unauthorized absences under the quality management program in R9-10-704.

evidence: Based on documentation review and interview, the administrator failed to evaluate and take action related to unauthorized absences under the quality management program in R9-10-704. The deficient practice posed a risk if the children's behavioral health facility did not take action to address unauthorized absences.

findings: 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described E3's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ongoing redirection and behavioral support to prevent recurrence." 2. A review of facility documentation revealed an incident report for R2. The incident report dated February 21, 2026, described a previous incident on an outing to the skate park and the elopement incident after returning to the facility from the skate park. The incident report stated, "On 02/21/2026 at approximately 8:10 PM, staff observed escalating behavior from client [R2] following earlier behavioral concerns involving peer [R1].... Staff provided clear expectations that [R2] should proceed to shower and then prepare for bed as scheduled. [R2] became increasingly frustrated and upset during the redirection. Shorty after, [R2] exited the home through the door without permission." 3. In an interview, E1 reported R1 exited the facility unauthorized out the front door after a phone call with a family member. E2 left the facility to look for R1. E3 remained at the facility and called the police. R2 exited the facility unauthorized out the back door. Police located and returned R1 and R2 who were away from the facility for twenty minutes. E1 reported R1 and R2 had no history of unauthorized absences and have not left unauthorized from the facility previously. 4. A review of facility documentation revealed a quality management plan. However, the quality management plan did not include information to evaluate and take action related to unauthorized absences. 5. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-704.1.a-e. Quality Management An administrator shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

evidence: Based on documentation review and interview, the administrator failed to establish a plan for an ongoing quality management program to include the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk if reports were not submitted to the governing authority.

findings: 1. A review of facility documentation revealed a quality management plan. However, the plan did not include the frequency of submitting a documented report required in subsection (2) to the governing authority. 2. In an interview, E1 reported quality reports on resident care are sent monthly to the insurance plans. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.

evidence: Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R1 and R2 left the facility unauthorized.

findings: 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described facility personnel's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ongoing redirection and behavioral support to prevent recurrence." 2. A review of facility documentation revealed an incident report for R2. The incident report dated February 21, 2026, described a previous incident on an outing to the skate park and the elopement incident after returning to the facility from the skate park. The incident report stated, "On 02/21/2026 at approximately 8:10 PM, staff observed escalating behavior from client [R2] following earlier behavioral concerns involving peer [R1].... Staff provided clear expectations that [R2] should proceed to shower and then prepare for bed as scheduled. [R2] became increasingly frustrated and upset during the redirection. Shorty after, [R2] exited the home through the door without permission." 3. In an interview, E1 reported R1 exited the facility unauthorized out the front door after a phone call with a family member. E2 left the facility to look for R1. E3 remained at the facility and called the police. R2 exited the facility unauthorized out the back door. Police located and returned R1 and R2 who were away from the facility for twenty minutes. E1 reported R1 and R2 had no history of unauthorized absences and have not left unauthorized from the facility previously. 4. A review of facility documentation revealed a staffing schedule. During the time of the incident, E2 was scheduled to work 3:00 PM- 9:00 PM and E3 was scheduled to work 7:00 PM-9:00 AM. 5. A review of facility documentation revealed policies and procedures. The "STAFFING OF RESIDENTIAL FACILITIES-EMPLOYEES... Policy:" stated, "A. The agency shall provide sufficient staff to provide the services, client supervision, and treatment; and to provide ancillary services to meet the scheduled and unscheduled needs of the client/consumer.... E. The agency shall provide sufficient staff to ensure the health, safety, and welfare of the client/consumer." 6. A review of facility documentation revealed policies and procedures. The policies and procedures revealed job descriptions. The job description for both the behavioral health technician and house manager position stated, "Recognize, prevent, and respond to situations in which a Consumer; may be a danger to self or others, behaves in an aggressive or destructive manner, may be experiencing a crisis situation or may be experiencing a medical emergency." 7. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated violation from the on-site compliance inspection on June 5, 2024 and on-site complaint inspections completed on October 3, 2025, October 20, 2025, November 5, 2025, and December 16, 2025.

rule: R9-10-706.G.3.f. 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: f. The individual ' s compliance with the requirements in A.R.S. § 8-804, if 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 the individual's compliance with the requirements in A.R.S. § 8-804(C), for two of two personnel members sampled. The deficient practice posed a risk if E2 and E3 were not qualified to work in a children's behavioral health residential facility.

findings: A.R.S. 8-804(C). "C. Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E2's and E3's personnel record revealed no documentation of a Department of Child Safety (DCS) central registry check being completed. 2. In an interview, E1 reported there was no DCS central registry check completed for personnel. E1 started the process to perform the checks while the Compliance Officer was on-site. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on documentation review and interview, the administrator failed to ensure that residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 and R2 left the facility unauthorized.

findings: 1. A review of facility documentation revealed an incident report for R1. The incident report dated February 21, 2026 described facility personnel's observations of a phone call where "[R1] becomes frustrated and upset toward [R1's family member]" and stated, "Staff verbally redirected [R1] at least three times during the phone call, instructing [R1] to communicate respectfully and honestly with [R1's family member]. [R1] was clearly warned that continued inappropriate communication would result in termination of phone privileges for that call. When [R1] continued the behavior, staff directed [R1] to end the call and get off the phone. At that time, [R1] became verbally escalated, raising [R1's] voice and yelling toward staff. Staff instructed [R1] to stop and utilize time to calm down. Following the directive, [R1] ran off from the immediate area. Staff conducted an immediate search of the premises but were unable to locate [R1]. Per protocol, staff contacted the non-emergency line to report the situation and request assistance. Staff will continue to monitor [R1's] phone interactions and provide ongoing redirection and behavioral support to prevent recurrence." 2. A review of facility documentation revealed an incident report for R2. The incident report dated February 21, 2026, described a previous incident on an outing to the skate park and the elopement incident after returning to the facility from the skate park. The incident report stated, "On 02/21/2026 at approximately 8:10 PM, staff observed escalating behavior from client [R2] following earlier behavioral concerns involving peer [R1].... Staff provided clear expectations that [R2] should proceed to shower and then prepare for bed as scheduled. [R2] became increasingly frustrated and upset during the redirection. Shorty after, [R2] exited the home through the door without permission." 3. In an interview, E1 reported R1 exited the facility unauthorized out the front door after a phone call with a family member. E2 left the facility to look for R1. E3 remained at the facility and called the police. R2 exited the facility unauthorized out the back door. Police located and returned R1 and R2 who were away from the facility for twenty minutes. E1 reported R1 and R2 had no history of unauthorized absences and have not left unauthorized from the facility previously. 4. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated violation from the on-site compliance and complaint inspection completed on June 5, 2024 and on-site complaint inspection completed on November 5, 2025 and December 16, 2025.


state: AZ

facility_name: ANGEL SAFE HAVEN LLC

summary: Complaint - 1/30/2026

raw_content: The following deficiency was found during the on-site  investigation of complaints 00156650 and 00157355 conducted on January 30, 2026:

inspection_type: Complaint

evidence: Based on observation, record review and interview, the administrator failed to ensure residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of Department documentation revealed the facility was licensed to provide services to individuals under 18 years of age. 2. The Compliance Officer observed, several times throughout the inspection, R1 was left unsupervised in the living room (with toxic chemicals within reach and unlocked doors to which R1 could have left the facility.) E1 and E2 were in the facility's office, with the door partially open, and neither could see R1 in the living room. 3. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 4. In an interview with E1, the Compliance Officer reported R1 was left unsupervised and without continuous protective oversight throughout the inspection (by E2 who was working) and demonstrated the current concern to E1. E1 acknowledged E2 should be providing continuous protective oversight at all times and called E2 into the room to oversee R1. 5. In an exit interview, the findings were reviewed with E1 (in person) and E7 (telephonically) and no additional comments or documentation were provided for review. This is a repeated violation from the complaint inspection conducted on December 16, 2025; the complaint inspection conducted on November 5, 2025; and the compliance and compliant inspection conducted on June 5, 2024.


summary: Complaint - 12/16/2025

raw_content: The following deficiencies were  found during the on-site investigation of complaints 00153285 and 00153286 conducted on December 16, 2025:

evidence: Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as R1 did not receive continuous protective oversight, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed a document titled "Angels Safe Haven Incident Report," dated December 12, 2025, completed by E1. The report stated "Client [R1] was seated at the kitchen table when [R1] requested to go outside stating [R1] wanted to walk. [R1]'s demeanor was calm. [R1] was unable to view TV due to loss of privileges for being suspended from school. Staff agree to allow [R1] to go outside in the back yard while [staff] observed [R1]. [R1] walked around the yard circling it several times when [R1] jumped on the wall. Staff immediately directed the member to get off the wall. The client ignored the redirection and proceeded to jump over the wall out of the yard. Staff immediately went out the front door with the remaining clients and proceeded to the side of the wall that [R1] had jumped to get [R1] however however [sic] the member had left the area. Staff immediately call [sic] Goodyear PD and proceeded to canvas the area to look for client." 2. In an interview with E1 (in person), E1 reported E1 and E2 were working at the facility when R1 jumped the back yard fence and proceeded to leave the yard. E1 reported E2 was with one resident in another part of the facility, and E1 followed R1 (with 3 other residents). E1 acknowledged the safety concern with taking multiple other residents outside the facility to search for R1 but reported the residents remained on the sidewalk during the search. 3. In an exit interview with E3 (telephonically), E3 reported in a situation of an unauthorized absence of a resident, the personnel member would follow the resident, then if near traffic, call 911, call the administrator, and call the resident's parent(s). E3 reported this protocol did not ensure the safety of residents. This is a repeated violation from the complaint inspections conducted on November 25, 2025; October 20, 2025; and October 3, 2025.

rule: R9-10-706.F.2. Personnel F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 2. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel members sampled. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of E2's (hired in 2025) personnel record revealed one negative skin test, dated in December 2025. However, a second skin test was not available for review. 2. A review of E2's personnel record revealed a baseline screening and risk assessment, however, the document was not reviewed and signed by a registered nurse or doctor. 3. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review.

rule: R9-10-706.G.3.e. 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: 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 observation, 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 A.R.S. § 36-425.03.A.E., for one of two personnel members sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. The Compliance Officer observed E2 at the behavioral health residential facility during the inspection on December 16, 2025. 2. In an interview, at 10:40 AM, E2 reported E2 worked the previous evening at the behavioral health facility from 9 pm and was scheduled to leave the facility at 9 am. E2 reported being at the facility upon the Compliance Officer's (8:30 AM) arrival but did not answer the door because E2 did not hear the Compliance Officer knocking. 3. A review of facility documentation revealed a daily staffing schedule dated Monday, December 8, 2025 - Sunday, December 14, 2025. The schedule revealed E2 was scheduled to work alone from 9 AM - 6 PM on December 13, 2025 and December 14, 2025. A second daily staffing schedule dated December 15, 2025 - Sunday, December 21, 2025 revealed E2 was scheduled to work on Monday, December 15, 2025 to Tuesday December 16, 2025 from 9 PM - 9 AM and 2 PM - 11 PM on December 16, 2025. 4. A review of E2's personnel record revealed E2 was hired as a behavioral health technician on December 4, 2025. However, E2's personnel record did not include evidence E2 had applied for a fingerprint clearance card, had filled out and had notarized a criminal history affidavit or had completed a central registry check. 5. In an interview, E2 reported E2 had applied for a fingerprint clearance card and provided information to the Compliance Officer. E2 stated E2 had been fingerprinted on December 5, 2025 and submitted an online application for a fingerprint clearance card. E2 provided the number 4A01746101, however, this number returned no results for a fingerprint clearance card. 6. In an interview, E1 provided the application number P559300705 for E2. 7. A review of the Arizona Department of Public Safety (AZDPS) Fingerprint Clearance Status website revealed the fingerprint clearance card status for E2 was "Not Valid" based on application number P559300705. 8. In an interview, E2 reported E2 had not received notification about E2's fingerprint clearance card results from AZDPS. E2 acknowledged E2 had not completed a criminal history affidavit. 9. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review. This is a repeated violation from the complaint inspection conducted on September 26, 2024, and the subsequent plan of correction inspection conducted on April 7, 2025. This is a repeated violation from the compliance and complaint inspection conducted on June 5, 2024.

rule: R9-10-706.K.3.b. Personnel 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, record review and interview, the administrator failed to ensure there was a daily staffing schedule to include documentation of the hours worked by each employee. The deficient practice posed a risk as there was no accurate record to verify sufficient, qualified personnel members and employees were present or available to meet the needs of the residents.

findings: 1. A review of facility documentation revealed a daily staffing schedule, dated Monday, December 8, 2025 - Sunday, December 14, 2025. The daily staffing schedule stated E2 was "OFF" on Thursday, December 11, 2025. 2. A review of R1's medical record revealed a document titled "Angel's Safe Haven Provider Daily Progress Note," dated December 11, 2025. The afternoon section was filled out and signed by E2 and stated the following "Client stayed home [R1] was sent home yesterday. Client has sat at dinner table all day + talked to pastor." 3. In an interview E1 acknowledged the daily staffing schedule reflected E2 was "OFF" and not scheduled to work on December 11, 2025, and E2 did actually work on December 11, 2025. 4. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review.

rule: R9-10-707.A.6. Admission; Assessment 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 registered nurse (RN) performed a nursing assessment on a resident within 72 hours after admission, for one of one resident sampled. The deficient practice posed a risk of not meeting a resident's needs if no physical examination were completed to assess a resident's needs prior to treatment, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed a document titled "Initial Health Screen," dated in October 2025, signed by the RN. However, the document was dated over a month after R1's admission date. 2. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and E3 reported the October 2025 date was made in error and E3 believed the document had been done a few days after R1's admission. E1 acknowledged the document was signed and dated by the RN a month after R1's admission. This is a repeated violation from the compliance inspection conducted on June 19, 2023.

rule: R9-10-708.A.4.c. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident to include the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign, 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, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed documentation which indicated R1 was under legal guardianship, with R1's guardian acting as R1's representative. 2. A review of R1's medical record revealed a treatment plan, dated in September 2025, with no signature of R1's representative, and date signed, or documentation of the refusal to sign. 3. A review of R1's medical record revealed an email sent to R1's representative, from E3, on October 23, 2025, asking for the treatment plan be signed. R1's guardian responded stating "Good morning. I will send the form back shortly. Thank you." However, documentation of R1's treatment plan signed by R1's representative was not available for review. 4. In a telephonic interview, E3 reported E3 had reached out to R1's representative on numerous occasions to get R1's representative to sign the treatment plan. However, R1's representative never signed R1's treatment plan. 5. In an exit interview, the findings were discussed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review. This is a repeated violation from the complaint inspection conducted on August 27, 2024, and the subsequent plan of correction inspection conducted on April 7, 2025.

evidence: Based on record review, documentation review and interview, the administrator failed to ensure residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 was not provided continuous protective oversight by the facility personnel at all times and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 2. A review of facility documentation revealed a document titled "Angels Safe Haven Incident Report," dated December 12, 2025, completed by E1. The report stated "Client [R1] was seated at the kitchen table when [R1] requested to go outside stating [R1] wanted to walk. [R1]'s demeanor was calm. [R1] was unable to view TV due to loss of privileges for being suspended from school. Staff agree to allow [R1] to go outside in the back yard while [staff] observed [R1]. [R1] walked around the yard circling it several times when [R1] jumped on the wall. Staff immediately directed the member to get off the wall. The client ignored the redirection and proceeded to jump over the wall out of the yard. Staff immediately went out the front door with the remaining clients and proceeded to the side of the wall that [R1] had jumped to get [R1] however however [sic] the member had left the area. Staff immediately call [sic] Goodyear PD and proceeded to canvas the area to look for client." 3. In an interview with E1 (in person), E1 reported E1 and E2 were working at the facility when R1 jumped the back yard fence and proceeded to leave the yard. E1 reported E2 was with one resident in another part of the facility, and E1 followed R1 (with 3 other residents). E1 acknowledged E1 lost sight of R1 and R1 was not provided continuous protective oversight. 4. In an exit interview, the findings were reviewed with E1 (in person) and E3 (telephonically) and no additional comments or documentation were provided for review. 5. A review of Department documentation revealed a police report from an incident that occurred on December 12, 2025 in which R1 was able to run away from the facility. The document stated "INITIAL DISPATCH: On 12/12/2025, at approximately 1721 hours, [O1] was dispatched to a missing juvenile call for service at the residence of [the facility] in the city of Goodyear. The caller, [E1], advised [R1] ran away from home by jumping the rear residential block wall last seen eastbound on foot. ATTEMPTS TO LOCATE: [R1] was promptly entered as missing, and common areas where [R1] ran away from [R1] might have gone, according to [E1], such as the parks surrounding the neighborhood, the Goodyear skatepark, GSQ Library, and [R1's school], were checked without results. LOCATING JUVENILE: During the investigation, an employee at Cowtown Skateshop (14175 W. Indian School Rd) called in advising that [R1] was at the store. Contact was made with [R1] who was promptly returned to [R1's] group home. This is a repeated violation from the complaint inspection conducted on November 5, 2025, and the compliance and compliant inspection conducted on June 5, 2024.


summary: Complaint - 11/5/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00148725 and 00149913 conducted on November 5, 2025.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as sufficient staff were not present to meet the unscheduled needs of the resident requiring continuous protective oversight.

findings: 1. A review of the facilities' policies and procedures revealed a policy titled "Staffing of Residential Facilities." The policy stated "...The agency shall provide sufficient staff to provide the services, client supervision, and treatment...." 2. A review of facility documentation revealed an incident report dated October 23, 2025. The incident report stated, "....Staff went to the office to get paper. Staff returned from the office and noticed that [R1] had gone and jumped the fence on the side of the house and left the premises. Staff tried to intervene, but [R1] ran down the street and walked left on [street name]. Staff began to follow the client in the van. Staff followed the client to the construction site, located at Encanto Blvd., where staff wasn't able to retrieve [R1]back in staff's possession. [R1] then got into the construction worker's truck, and the construction worker called the police. The police retrieved [R1] and called the CEO and Admin. Staff returned to the house and retrieved the client from the police." 3. In an interview, R1 reported leaving the behavioral health facility without notifying staff, reportedly due to an argument with peers. R1 reported that facility staff initially followed R1 after leaving the facility in a van. R1 reported that the staff were not present at the construction site, and R1 was alone with the construction workers for approximately thirty minutes. R1 reported that a police officer picked up R1 from the construction site and brought R1 to the station. 4. In an interview, E2 reported that the facility staff gathered the other residents in the facility van after R1 left the facility. E2 reported that the staff followed R1 in the van. E2 reported the staff had "eyes" on R1 the entire time until R1 remained at the construction site and refused to leave with the staff. E2 reported that R1 was then taken to the police station and was not under the supervision of the facility personnel.

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure that there was a daily staffing schedule that included documentation of the employees who work each calendar day and the hours worked by each employee. The deficient practice posed a risk as the schedule does not include the correct staffing to verify compliance.

findings: 1. The Compliance Officer observed E1 and E2 working at the facility at the time of the inspection. 2. A review of the facilities staffing schedule revealed the current week's schedule. The schedule revealed that on November 4, 2025, and November 5, 2025, E3 was scheduled to work from 9:00 AM to 5:00 PM. 3. In a phone interview, E3 reported E3 was in California and did not work on November 4, 2025, and was not currently at the facility on November 5, 2025, from 9:00 AM to 5:00 PM. 4. In an interview, E2 acknowledged E3 was identified to be working at the facility. E2 acknowledged that the administrator failed to ensure that there is a daily staffing schedule that includes documentation of the employees who work each calendar day and the hours worked by each employee.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as a minor child was not supervised by the facility personnel at all times.

findings: 1. A review of R1's medical record revealed R1 was a minor admitted to the behavioral health residential facility requiring continuous protective oversight. 2. In an interview, R1 reported leaving the behavioral health facility without notifying staff, reportedly due to an argument with peers. R1 reported that facility staff initially followed R1 after leaving the facility in a van. R1 reported that the staff were not present at the construction site, and R1 was alone with the construction workers for approximately thirty minutes. R1 reported that a police officer picked up R1 from the construction site and brought R1 to the station. 3. A review of an incident report dated October 23, 2025, revealed "....Staff went to the office to get paper. Staff returned from the office and noticed that [R1] had gone and jumped the fence on the side of the house and left the premises. Staff tried to intervene, but [R1] ran down the street and walked left on [street name]. Staff began to follow the client in the van. Staff followed the client to the construction site, located at Encanto Blvd., where staff wasn't able to retrieve [R1]back in staff's possession. [R1] then got into the construction worker's truck, and the construction worker called the police. The police retrieved [R1] and called the CEO and Admin. Staff returned to the house and retrieved the client from the police." 4. In an interview, E2 reported that the facility staff gathered the other residents in the facility van after R1 left the facility. E2 reported that the staff followed R1 in the van. E2 reported the staff had "eyes" on R1 the entire time until R1 remained at the construction site and refused to leave with the staff. E2 reported that R1 was then taken to the police station and was not under the supervision of the facility personnel.


summary: Complaint - 10/22/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00148421 and 00148461 conducted on October 22, 2025:

rule: R9-10-703.C.2.d. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: d. Cover emergency safety responses;

evidence: Based on documentation review and record review, the administrator failed to document policies and procedures for behavioral health services to protect the health and safety of a resident that covered emergency safety responses (ESR.) The deficient practice posed a risk as a behavioral health residential facility is not authorized to conduct seclusions or restraints.

findings: 1. A review of facility documentation revealed an undated policy and procedure titled "Abnormal Behaviors, Behavioral Emergency, Behavioral Management." The document stated "II Policy:...I. Only staff members that have attended and successfully completed a nationally recognized Crisis Prevention Intervention\Emergency Safety Response course may use physical restraint on a client/consumer who is a danger to herself to prevent them from harm or harming others. J. Staff certified in Crisis Prevention Intervention\Emergency Safety Response use the least restrictive means of restraint to ensure the care, welfare, safety and security for the client/consumer and others." 2. A review of facility documentation revealed an undated policy and procedure titled "Emergency Safety Response/Seclusion and Restraint." 3. A review of facility documentation revealed an undated training manual for the Emergency Safety Response curriculum, titled "Therapeutic Crisis Intervention (TCI) - Student Workbook, Seventh Edition." The curriculum discussed and trained on the use of restraints. The curriculum stated "The use of physical restraint is a complex issue...As a result, six core strategies have been identified and approved as evidence-based practices that reduce coercion, violence and the use of seclusion and restraints." 4. A review of E2's, E3's, E5's, E6's, E7's personnel records included trainings to the TCI program. 5. In an exit interview, E1 stated E1 trained all facility personnel to the TCI program. E1 acknowledged the TCI curriculum included the word "restraint" and reported to be under the impression restraints were allowed if they were used as ESRs.

rule: R9-10-706.G.3.h. 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: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of cardiopulmonary resuscitation (CPR) training. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed daily staffing schedules, dated October 13 -19, 2025 and October 20 - 26, 2025. The staffing schedules revealed E5 worked the 11:00 PM-8:00 AM shifts alone at the facility as a behavioral health technician. 2. A review of E5's personnel record revealed a Healthcare Provider CPR/AED: Adult, Child & Infant + First Aid" certificate, dated January 20, 2025. However, the training was from an online program and did not include demonstration of CPR. 3. In an exit interview, E1 acknowledged the CPR training document in E5's personnel record was from an online program and did not include a demonstration. E1 reported to be under the impression E5 had an additional CPR training document, however, E1 was unable to provide the CPR demonstration documentation for review. This is a repeated violation from the compliance inspection conducted on May 31, 2022; the compliance inspection conducted on June 19, 2023; the complaint investigation/compliance inspection conducted on June 5, 2024; and the complaint investigation conducted on September 26, 2024.

rule: R9-10-706.J.1. Personnel J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations served by the behavioral health residential facility: 1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and

evidence: Based on documentation review, record review and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation of the behavioral health residential facility who had cardiopulmonary resuscitation (CPR) training to include a demonstration. The deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed daily staffing schedules, dated October 13 - 19, 2025 and October 20 - 26, 2025. The staffing schedules revealed E5 worked the 11:00 PM-8:00 AM shifts alone at the facility as a behavioral health technician. 2. A review of E5's personnel record revealed a Healthcare Provider CPR/AED: Adult, Child & Infant + First Aid" certificate, dated January 20, 2025. However, the training was from an online program and did not include a demonstration. 3. In an exit interview, E1 acknowledged the CPR training document in E5's personnel record was from an online program and did not include a demonstration. E1 reported to be under the impression E5 had an additional CPR training document, however, E1 was unable to provide CPR demonstration documentation for review. E1 acknowledged E5 worked shifts alone at the behavioral health facility. This is a repeat violation from the compliance inspection conducted on June 19, 2023; and the complaint investigation and compliance inspection conducted on June 5, 2024.

rule: R9-10-708.A.6.d. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 6. Is reviewed and updated on an on-going basis: d. When a resident has a significant change in condition or experiences an event that affects treatment.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a treatment plan was updated when a resident had a significant change in condition or experienced an event that affected treatment. The deficient practice posed a risk as a treatment plan was not updated to articulate decisions and agreements of services to be provided, and posed a risk if the resident's treatment needs were not consistent with the services BH6115 was authorized and able to provide.

findings: 1. A review of R1's medical record revealed an untitled document, dated October 9, 2025. The document stated the following "The member currently does not have 24-hour supervision, and the BHRF is unable to provide this level of care. Even with 1:1 staffing, the facility reports concerns about their capacity to safely manage the member's behaviors. A BHIF provides the locked, highly structured and medically supervised environment required to ensure [R1's] safety, stabilize [R1's] behaviors and deliver intensive, daily therapeutic support." Additionally, the document stated "Current clinical and behavioral concerns: Elopement: has left the current BHRF approximately 10 times, at times requiring crisis intervention...Suicidal statements: Expresses self-harm thoughts to avoid tasks or gain attention, later recanting...Next steps: The High Needs Case Coordinator will initiate a referral for Behavioral Health Inpatient Facility (BHIF) placement to ensure the member receives the appropriate level of care. The member will continue to receive one-on-one support within the current BHRF placement...." The document additionally revealed R1 had been in a psychiatric hospital between September 26 - October 7, 2025. 2. A review of R1's medical record revealed a treatment plan, dated September 26, 2025. However, an updated treatment plan, after October 9, 2025, was not available for review. 3. In an exit interview, E1 acknowledged R1's treatment plan had not been updated to reflect R1's change in condition.

rule: R9-10-709.C. Discharge C. An administrator shall ensure that a resident is discharged from a behavioral health residential facility when the resident's treatment needs are not consistent with the services that the behavioral health residential facility is authorized and able to provide.

evidence: Based on record review, documentation review and interview, the administrator failed to ensure a resident was discharged from a behavioral health residential facility when the resident's treatment needs were not consistent with the services that the behavioral health residential facility was authorized and able to provide. The deficient practice posed a risk if R1 was a danger-to-self or a danger-to-others.

findings: R9-10-101.36. “Behavioral health residential facility” means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual’s ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. 1. A review of R1's medical record revealed an untitled document, dated October 9, 2025. The document stated the following "The member currently does not have 24-hour supervision, and the BHRF is unable to provide this level of care. Even with 1:1 staffing, the facility reports concerns about their capacity to safely manage the member's behaviors. A BHIF provides the locked, highly structured and medically supervised environment required to ensure [R1's] safety, stabilize [R1's] behaviors and deliver intensive, daily therapeutic support." Additionally, the document stated "Current clinical and behavioral concerns: Elopement: has left the current BHRF approximately 10 times, at times requiring crisis intervention...Suicidal statements: Expresses self-harm thoughts to avoid tasks or gain attention, later recanting...Next steps: The High Needs Case Coordinator will initiate a referral for Behavioral Health Inpatient Facility (BHIF) placement to ensure the member receives the appropriate level of care. The member will continue to receive one-on-one support within the current BHRF placement...." 2. A review of facility documentation revealed daily staffing schedules, dated October 13 - 19, 2025 and October 20 - 26, 2025. The schedules revealed the facility scheduled a 1:1 for R1 on the following days: October 13 (5:00 PM-9:00 PM); October 14 (5:00 PM-9:00 PM); October 15 (5:00 PM-9:00 PM); October 16 (5:00 PM-9:00 AM)[sic]; October 17 (5:00 PM-9:00 PM); October 18 (9:00 AM-7:00 PM); October 19 (10:00 AM-8:00 AM)[sic], October 20 (5:00 PM-9:00 PM); October 21 (5:00 PM-9:00 PM); October 22 (6:00 PM-11:00 PM); October 23 (5:00 PM-9:00 PM); October 24 (5:00 PM-9:00 PM); October 25 (12:00 PM-8:00 PM); and October 26 (10:00 AM-8:00 AM)[sic]. 3. A review of facility documentation revealed a document titled "Angels Safe Haven Incident Report," dated October 21, 2025 and signed by E5. The document stated "When the van arrived to pick [R1] up for school while being escorted to the van by the attendant...[R1] would not get in the van [R1] would jump out of the van the attendant continue [sic] and proceeded to run around the corner down the street. Angel Safe Haven staff was notified and follow [sic] [R1] down the street making attempt to retrieve [R1]. [R1] continue [sic] to walk away refused to return [R1] then ran into street." The document stated the facility proceeded to notify law enforcement. 4. A documentation review of a police report revealed the following: On 10/21/25 at approximately 0733 hours, [O1] responded to welfare check in the area of Bullard and Encanto Blvd. Dispatch advised [R1] left the house and was refusing to go to school. [R1] was walking south on Bullard Rd toward Encanto Blvd. Prior to [O1's] arrival [O1] was advised [O2] was out with [R1] and the reporting party at Encanto Blvd and South Bullard Rd. Upon arrival [O1] spoke with [O2.] [O1] was advised [R1] identified as was in there [sic] vehicle ad [sic] [E5] was in the white van with another of the kids from the home. [O1] spoke to the reporting party [E5]. [O1] asked what happened this morning and [E5] stated [R1] did not want to get up and go to school. [E5] stated [R1] rides a bus to [R1's] school. [E5] stated when [R1] finally got up and when [R1] was going outside to get on the bus, [R1] went left and refused ot [sic] go to [R1's school.] [R1] kept walking away form the house. [E5] stated [E5] followed down Bullard with the other special needs child in the van. [E5] stated [R1] was crossing the street. [E5] advised could not get [R1]to stop. [E5] advised that [R1] is SMI and takes medication. 5. In an exit interview, the findings were reviewed with E1 and E1 acknowledged R1's medical record indicated R1 needed a higher level of care (as documented on October 9, 2025) and R1 was to have a 1:1. E1 reported a 1:1 was only scheduled for R1 a few days a week in the evenings, for 4 hours, though R1's medical record indicated R1 was supposed to have 1:1 staffing. E1 reported R1 had been outside of the facility's scope and the facility tried discharging the resident prior but received pushback from R1's case management team. E1 acknowledged R1 should have been discharged when it was identified R1 needed a 1:1.


summary: Complaint - 10/20/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00148122 conducted on October 20, 2025:

evidence: Based on documentation review and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to to ensure the health and safety of a resident. The deficient practice posed a risk as a resident was at the premise when no personnel members were present.

findings: 1. A review of facility documentation revealed an incident report dated October 16, 2025. The incident report stated, "[E4] arrived about 10 min late to my shift due to an accident on the freeway. Upon arrival Goodyear PD was on the scene with [R1] and alluded [sic] the school had dropped [R1] off early due to [R1's] behaviors on the van. The other staff had left with the other clients to the Dr. appointments. I contacted management for PD and [sic] took over care of [R1]. No other issues to report." 2. A review of facility documentation revealed a staffing schedule. The staffing schedule revealed on October 16, 2025 E1 was scheduled to work 5:00 PM-9:00 PM for 1:1 coverage with R1, E2 was scheduled 8:00 AM-2:00 PM, E3 was scheduled 8:00 AM-6:00 PM, and E4 was scheduled 4:00 PM-9:00 PM. 3. A review of facility documentation revealed policies and procedures. The "STAFFING OF RESIDENTIAL FACILITIES-EMPLOYEES... Policy:" stated, "A. The agency shall provide sufficient staff to provide the services, client supervision, and treatment; and to provide ancillary services to meet the scheduled and unscheduled needs of the client/consumer.... E. The agency shall provide sufficient staff to ensure the health, safety, and welfare of the client/consumer... I. The agency shall provide at least one (1) staff member at the facility during hours of operation." 4. In an interview, E1 reported no personnel members were on the premise when R1 arrived home early from school because E3 was off-premise with other residents for doctor appointments. The school did not notify the facility of R1's early drop off. 5. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. 6. A review of documentation revealed a Goodyear Police Department Case Report. The Case Report stated, "on 10/16/25 at approximately 1517 hours, [O1] responded to a welfare check call for service at Angels Safe Haven LLC group home, Goodyear AZ. Prior to arrival [O2] and [O3] were on scene. They advised [O1] that resident [R1] was brought home from school and no one was at the group home to receive [R1]... We attempted to contact the house manager, staff, and home owner. No one answered and messages were left. We waited for over approximately an hour. We were able to finally have one of the staff members contact. Staff member [E3], called back and advised that [R1] was not supposed to be home until 1630 hours from school. [E3] stated [E3] was busy up north on I-17 and Cactus Rd, picking up the 3 other kids, for the home. [E3] stated [E3] would not be able to respond back to the home anytime soon. A short time later [O1] spoke with [E1] the house manager. [E1] advised [E1] was the house manager. [E1] was advised on what happened and no one was at the home to greet [R1]. [E1] stated that no one was supposed to be there when no child is at the home. [E1] stated [E1] was up north riding [E1's] motorcycle and was not near the residence. [O1] asked [E1] what would happen during an emergency if no one was around. What if they were needed. [E1] replied that [E1] does not keep people there when no one is in the home. [E1] advised that they can call [E1] phone number. [O1] advised [E1] that we have been calling and [E1] did not pick up. [E1] stated they were unknown numbers. I advised [E1] [E1] has a duty to pick up no matter what the time or reason because these are kids, and you are running a kids group home. [E1] stated [E1] would let the owner know. Prior to the phone conversation ending a staff member drove up identified as [E4]. [E4] stated [E4] was the staff member that was supposed to show up at 1630 hours to receive [R1]. [E4] advised no one called from the school to tell them [R1] was coming home at 1500 hours. [E4] stated [E4] would take [R1] into the residence. This is a repeated violation from the on-site complaint inspection completed on June 4, 2024.

rule: R9-10-706.K.1. Personnel K. An administrator shall ensure that: 1. At least one personnel member is present and awake at the behavioral health residential facility when a resident is on the premises;

evidence: Based on documentation review and interview, the administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises. The deficient practice posed a risk as a resident was at the premise when no personnel members were present.

findings: 1. A review of facility documentation revealed an incident report dated October 16, 2025. The incident report stated, "[E4] arrived about 10 min late to my shift due to an accident on the freeway. Upon arrival Goodyear PD was on the scene with [R1] and alluded [sic] the school had dropped [R1] off early due to [R1's] behaviors on the van. The other staff had left with the other clients to the Dr. appointments. I contacted management for PD and [sic] took over care of [R1]. No other issues to report." 2. A review of facility documentation revealed a staffing schedule. The staffing schedule revealed on October 16, 2025 E1 was scheduled to work 5:00 PM-9:00 PM for 1:1 coverage with R1, E2 was scheduled 8:00 AM-2:00 PM, E3 was scheduled 8:00 AM-6:00 PM, and E4 was scheduled 4:00 PM-9:00 PM. 3. A review of facility documentation revealed policies and procedures. The "STAFFING OF RESIDENTIAL FACILITIES-EMPLOYEES... Policy:" stated, "K. The agency shall ensure that at least one (1) staff member is present and awake at the facility at all times when a client/consumer is on the premise." 4. In an interview, E1 reported no personnel members were on the premises when R1 arrived home early from school because E3 was off-premises with other residents for doctor appointments. The school did not notify the facility of R1's early drop-off. 5. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. 6. A review of documentation revealed a Goodyear Police Department Case Report. The Case Report stated, "on 10/16/25 at approximately 1517 hours, [O1] responded to a welfare check call for service at Angels Safe Haven LLC group home, Goodyear AZ. Prior to arrival [O2] and [O3] were on scene. They advised [O1] that resident [R1] was brought home from school and no one was at the group home to receive [R1]... We attempted to contact the house manager, staff, and home owner. No one answered and messages were left. We waited for over approximately and hour. We were able to finally have one of the staff members contact. Staff member [E3], called back and advised that [R1] was not supposed to be home until 1630 hours from school. [E3] stated [E3] was busy up north on I-17 and Cactus Rd, picking up the 3 other kids for the home. [E3] stated [E3] would not be able to respond back to the home anytime soon. A short time later [O1] spoke with [E1] the house manager. [E1] advised [E1] was the house manager. [E1] was advised on what happened and no one was at the home to greet [R1]. [E1] stated that no one was supposed to be there when no child is at the home. [E1] stated [E1] was up north riding [E1's] motorcycle and was not near the residence. [O1] asked [E1] what would happen during an emergency if now one was around. What if they were needed. [E1] replied that [E1] does not keep people there when no one is in the home. [E1] advised that they can call [E1] phone number. [O1] advised [E1] that we have been calling and [E1] did not pick up. [E1] stated they were unknown numbers. I advised [E1] [E1] has a duty to pick up no matter what the time or reason because these are kids, and you are running a kids group home. [E1] stated [E1] would let the owner know. Prior to the phone conversation ending a staff member drove up identified as [E4]. [E4] stated [E4] was the staff member that was supposed to show up at 1630 hours to receive [R1]. [E4] advised no one called from the school to tell them [R1] was coming home at 1500 hours. [E4] stated [E4] would take [R1] into the residence.

rule: R9-10-720.C.3. Emergency and Safety Standards C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on observation and interview, the administrator failed to ensure a current fire inspection report was maintained. The deficient practice posed a potential risk to the health and safety of a resident in the event of a fire if hazards were not identified and corrected and standards expected of the facility were not followed.

findings: 1. The Compliance Officer observed an expired Fire Permit was posted in the facility. 2. The Compliance Officer requested to review a current fire inspection report. However, a current fire inspection report was not provided while the Compliance Officer was on-site. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 10/3/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00146282 conducted on October 3, 2025:

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility’s premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of residents. The deficient practice posed a risk to resident safety, as inadequate staffing contributed to a resident leaving the facility unsupervised.

findings: 1. A review of facility documentation revealed an incident report dated September 30, 2025 stated "Client [R1] asked to use the restroom. While staff [E4] was conversing and interacting with other clients, [R1] walked out the front door. Staff [E4] went outside to the front to look for [R1] and noticed [R1] was sitting in the house van. Staff [E4] redirected client [R1] to get out of vehicle, which [R1] complied and got out. Staff [E4] directed [R1] to come back in the house , which [R1] did not comply and began walking away from the house east bound down Cambridge Ave towards Bullard. Staff [E4] went and got the other 3 clients inside the house and began looking and following [R1] when [R1] was no longer in view. After catching up with [R1] at Bullard and Cambridge intersection, [R1] became combatant [sic] with 2 of the other clients [R2] and [R3] by hitting them when they approached. Staff [E4] attempted to guide and direct [R1] back home, which [R1] refused and began kicking [R1] shoes off, pulling down [R1] pants, and started shouting that [R1] was going to kill [R1]." 2. In an interview, E1 reported that there was one personnel on shift at the time of the incident and that it is common practice for only one personnel to be scheduled during that shift. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided regarding the findings.

rule: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on documentation review and record review, the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented personal history. The deficient practice posed a risk as a resident had access to a metal bar while admitted into a behavioral health residential facility, in contradiction to their behavioral health issue.

findings: 1. A review of facility documentation revealed a incident report dated September 19, 2025. The incident report stated "Client [R1] peed on the floor after undressing and touching [R1] private parts. Client [R1] played in [R1] urine client [R1] later was naked in room and trashing [R1's] room and breaking the blinds. Staff [E3] told [R1] to put clothes on and [R1] complied by continue to damage property and was disorderly. Staff [E3] had to remove a medal [sic] bar from client [R1] when client [R1] tried to use it as a weapon on staff [E3]. Client [R1] was placed in a hold for 5 minutes. Police and Fire were notified but did not do their jobs concerning the disorderly conduct and property damage staff [E3] tried to contact Fire for client [R1] to be evaluated and fire said that was not their job. Struggles with client [R1] continued for 3 hours. CPI hold x5 (3 minutes at a time for safety)." 2. A review of R1's medical record (admitted 2025) revealed a behavioral health assessment dated March 3, 2025. The assessment revealed R1 “was recently discharged from hospitalization following stabilization after crisis,” and has a “history of expressing suicidal ideation, including verbalizing thoughts of wanting to jump into traffic.” The assessment also documented R1 “has exhibited physical aggression, including initiating fights with peers and adults during times of crisis.”  3. In an exit interview, the findings were reviewed with the administrator, and no additional comments or statements were provided regarding the findings.

rule: R9-10-716.E.2.c. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: c. The specific emergency safety response used;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that within 24 hours after an emergency safety response was used for a resident, the specific emergency safety response used was entered into the resident’s medical record. This deficient practice posed a risk of incomplete documentation regarding the use of emergency safety interventions.

findings: 1. A review of facility documentation revealed an incident report dated September 19, 2025, stated "Client [R1] peed on the floor after undressing and touching [R1] private parts. Client [R1] played in [R1] urine client later was naked in room and trashing [R1's] room and breaking the blinds. Staff [E3] told [R1] to put clothes on and [R1] complied by continue to damage property and was disorderly. Staff had to remove a medal [sic] bar from client [R1] when client [R1] tried to use it as a weapon on staff [E3]. Client [R1] was placed in a hold for 5 minutes. Police and Fire were notified but did not do their jobs concerning the disorderly conduct and property damage staff [E3] tried to contact Fire for client to be evaluated and fire said that was not their job. Struggles with client [R1] continued for 3 hours. CPI hold x5 (3 minutes at a time for safety)." However, the incident report did not include the specific emergency response used. 2. A review of R1’s medical record revealed no documentation of the specific emergency safety response used following the incident on September 19, 2025. The facility did not provide documentation to demonstrate that the emergency safety response was entered into the medical record within 24 hours, as required.  3. In an exit interview, the findings were reviewed with the administrator, and no additional comments or documentation were provided regarding the findings.


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

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

inspection_type: Compliance (Annual)

rule: R9-10-113.A.2.a-f. 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: 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, baseline 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, occupation 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 documentation review and interview, the health care institution's chief administrative officer failed to establish and document tuberculosis (TB) infection control activities to include annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of facility documentation revealed no TB infection control activities to include, annual training and education related to recognizing the signs and symptoms of TB. 2. In a joint interview, E1 and E2 reported the facility’s TB education program was at another location and was not available for review.  3. In a joint exit interview, the findings were reviewed with E1 and E2, and no further documentation or comment was provided.

rule: R9-10-706.G.3.g. 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: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that includes documentation of clinical oversight as required by R9-10-115 for a behavioral health technician, for two of five personnel records sampled. The deficient practice posed a risk if individuals not qualified to provide behavioral health services did not receive training from a licensed individual.

findings: 1. A review of E2's (hired as a behavioral health technician) and E4's (hired as a behavioral health technician) personnel records revealed no documentation of clinical oversight from a behavioral health professional (BHP). 2. A review of facility documentation revealed group counseling sessions. The dates of the counseling were from July 3, 2025, through August 7, 2025, and were conducted by E2 and E4. 3. In an interview with E1 and E2, it was reported that the facility had been closed and reopened in July. E2 reported clinical oversight had not been conducted since the facility reopened. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-718.C.6.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and

evidence: Based on record review and interview, the behavioral health residential facility failed to provide assistance in the self-administration of medication and ensure that the resident was taking the medication in compliance with an order, for one of two resident records sampled.

findings: 1. A review of R2's medical record revealed a medication order from a medical practitioner for “Clondine HCI 0.1 mg tablet - Take 1 tab po qhs”. 2. A review of R2's medical record revealed a medication administration record (MAR), which revealed the aforementioned medication was taken at 8:00 AM and not at bedtime. 3. A review of R2's medical record revealed a medication order from a medical practitioner for “Hydroxyzine pamoate 25 mg capsule - Take 1 tab po q 6hrs prn anxiety." 4. A review of R2's MAR revealed the description and instructions stated on the MAR were incorrect. The MAR stated, "Hydroxyzine. Dosage: 50mg. Instructions/Route: Every six hours PRN.” 5. In an interview, E2 reported the current medication orders were the most recent orders. 6. In an exit interview, the findings were reviewed with E1 and E2 and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 4/7/2025

rule: 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

rule: C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

rule: K. An administrator shall: 7. If a resident's absence is unauthorized as determined according to the criteria in subsection (K)(6), within an hour after determining that the resident's absence is unauthorized, notify: a. For a resident who is under 18 years of age, the resident's parent or legal guardian; and

rule: An administrator shall ensure that: 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and

rule: B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.

rule: F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and 2. As specified in R9-10-113.

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: b. The individual's education and experience applicable to the individual's job duties;

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;

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: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e); i. First aid training, if required for the individual according to this Article or policies and procedures; and

rule: J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations served by the behavioral health residential facility: 1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and

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.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident's treatment needs; and

rule: G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge;

rule: C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

rule: C. An administrator shall ensure that a resident's medical record contains: 15. Documentation of behavioral health services and physical health services provided to the resident;

rule: A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

rule: C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and

rule: C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and

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: b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

rule: B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: iii. Toilet tissue for each toilet,

rule: B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: v. Paper towels in a dispenser or a mechanical air hand dryer,


summary: Complaint - 4/7/2025

rule: 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;

rule: C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

rule: B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.

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: j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

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: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment; b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;