summary: Compliance (Annual) - 4/14/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of December 1, 2022 through November 30, 2023, 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.


state: AZ

facility_name: EAGLES NEST BOYS & GIRLS RESIDENTIAL AGENCY

summary: Complaint;Compliance (Annual) - 12/22/2025

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaint 00125191 conducted on December 22, 2025:

inspection_type: Complaint;Compliance (Annual)

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 which included documentation of the individual's compliance with the requirements in A.R.S. § 8-804, for four of four personnel records sampled. The deficient practice posed a risk to the health and safety of residents if staff were unfit to work at a children's behavioral health residential facility.

findings: A.R.S. § 8-804(K) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E2's, E3's, E4's, and E5's personnel records revealed no documentation demonstrating the licensee submitted to the Department of Child Safety in a manner prescribed by the Department of Child Safety, information necessary to conduct a central registry background check on E2, E3, E4, and E5. 2. In an interview, E1 reported E1 did not submit to the Department of Child Safety in a manner prescribed by the Department of Child Safety, information necessary to conduct a central registry background check on E2, E3, E4, and E5. 3. In an exit interview, the findings were reviewed with E1, and no further documentation or comment was provided.


summary: Complaint;Compliance (Annual) - 12/3/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00214293 and AZ00215110 conducted on December 3, 2024:

rule: 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: f. Cover dispensing medication, administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover administering medication. The deficient practice posed a risk as the facility's standards were not implemented and the Department was provided false and misleading information.

findings: 1. A review of the facility policies and procedures revealed a policy titled, "DISPENSING MEDICATION" dated January 5, 2023. The policy stated, "...C. Ensure the medication paperwork and the medication container match before dispensing the medication to the client...e. Check the dose of the medication container and be sure it is identical to the dosage on the medication paperwork. f. Ensure every letter and number on the medication orders match the medication package, tablet, capsule, suppository, liquid or some other form medication log. g. Ensure the medication instructions are the same on the medication container and medication log..." 2. A review of R1's medical record revealed a document titled "Medication Reconciliation" dated November 21, 2024. The document stated "START: Escitalopram 5 mg by mouth once a day...STOP: Paroxetine 10 mg daily..." 3. A review of R1's medication administration record (MAR) for the month of December 2024 revealed R1 received assistance in the self-administration of medication for the following medications: -Escitalopram 5 mg December 1-3, 2024 at 7:00 AM -Paroxetine HCL 10 mg December 1-2, 2024 at 7:00 PM 4. In an interview, E1 reported the staff administer R1's from a medication organizer which is set up in advance by E1 7 days at a time. E1 reported R1 did not receive "Paroxetine HCL 10 mg" since it was discontinued on November 21, 2024, yet staff documented "Paroxetine HCL 10 mg" being issued to R1. E1 acknowledged policies and procedures to protect the health and safety of a resident to cover administering medication were not implemented, and the Department was provided false and misleading information.

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.

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 Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) for one of four personnel sampled. The deficient practice posed a potential TB infection risk to residents.

findings: Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). 1. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 2. A review of E3's personnel record (hired in 2024) revealed E3's personnel record included an initial TST test completed on August 2, 2024. However, documentation of E2's freedom of infectious TB, per R9-10-113 (A)(2)(iii) of two-step testing, was not available for review. 3. In an interview, E1 acknowledged documentation of evidence of freedom from infectious TB, as specified in R9-10-113(B)(1)(a)(i) was not available for review.

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 two residents sampled. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of R2's medical record revealed documentation R2 provided evidence of freedom from infectious TB before or within seven calendar days after R2's admission date was not available for review. Based on R2's admission date, documentation of evidence of freedom from infectious TB was required. 2. In an interview, E1 acknowledged R2 did not provide evidence of freedom from infectious TB before or within seven calendar days after R2's admission.

rule: 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 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 two residents sampled.

findings: 1. A review of R1's medical record revealed a current treatment plan (dated in 2024). However, the signature R1's representative, and date signed, or documentation of the refusal to sign was not available for review. 2. In an interview, E1 acknowledged R1's treatment plan did not include the signature of R1's representative, and date signed, or documentation of the refusal to sign.

rule: A. An administrator shall ensure that: 3. An order is: b. Authenticated by a medical practitioner or behavioral health professional according to policies and procedures; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure an order was authenticated by a medical practitioner or behavioral health professional (BHP) according to policies and procedures. The deficient practice posed a risk as medication taken by the resident could not be verified against a medication order.

findings: 1. A review of the facility policies and procedures revealed a policy titled, "REGIMEN MEDICATION POLICY" dated January 5, 2023. The policy stated, "Any order for a prescribed medication, treatment, referral, or procedure shall be documented on a progress note with the signature of the practitioner. Medication orders must be logged into the client record. Phone orders may only be accepted by the pharmacy or a register nurse. A copy of the order shall be co-signed by the practitioner within 48 hours." 2. A review of R1's medical record revealed a document titled "Medication Reconciliation" dated November 21, 2024. The document stated "START: Escitalopram 5 mg by mouth once a day...STOP: Paroxetine 10 mg daily..." However, the order was not authenticated by a medical practitioner or BHP according the facility's policies and procedures. 3. In an interview, E1 acknowledged the orders were not authenticated by a medical practitioner or BHP according the facility's policies and procedures.


summary: Compliance (Annual) - 12/14/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 14, 2023:

inspection_type: Compliance (Annual)

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 two residents sampled.

findings: 1. A review of R2's (admitted in May 2023) medical record revealed a nursing assessment. However, the nursing assessment was completed six days after R2's date of admission. 2. In an interview, E1 acknowledged a nursing assessment for R2 was not performed within 30 calendar days before admission or within 72 hours after admission.

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: a. Documents a resident's: i. Presenting issue; ii. Substance abuse history; iii. Co-occurring disorder; iv. Legal history, including: (1) Custody, (2) Guardianship, and (3) Pending litigation; v. Criminal justice record; vi. Family history; vii. Behavioral health treatment history; viii. Symptoms reported by the resident; and ix. Referrals needed by the resident, if any;

evidence: Based on record review and interview, the administrator failed ensure a behavioral health assessment documented a resident's substance abuse history, co-occurring disorder, family history; and health treatment history, for one of two residents sampled.

findings: 1. A review of R2's medical record revealed a behavioral health assessment titled "Eagle's Nest Treatment Plan/Assessment" dated in May 2023. However, R1's behavioral health assessment did not include the following: -Substance abuse history, -Co-occurring disorder, -Family history, and -Behavioral health treatment history. 2. In an interview, E1 acknowledged R2's behavioral health assessment did not document all required components.

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 and as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of R1's medical record revealed a chest x-ray completed in August 2023. The chest x-ray stated ..."no radiographic evidence of active pulmonary tuberculosis." However, documentation to demonstrate R1 had a history of tuberculosis or documentation of latent tuberculosis infection was not available for review. 2. In an interview, E1 reported to be unaware a chest x-ray was not an acceptable form of freedom from infectious TB. E1 acknowledged R1 did not provide evidence of freedom from infectious TB before or within seven calendar days after R1's admission.


facility_name: TREE OF LIFE ARIZONA

summary: Compliance (Annual) - 11/7/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on November 7, 2025.


summary: Compliance (Annual) - 10/24/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 24, 2024.


summary: Complaint - 8/5/2024

raw_content: An on-site investigation of complaint AZ00214089 was conducted on August 5, 2024, and the following deficiency was cited :

inspection_type: Complaint

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility ' s employee or personnel member, the administrator shall: 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (I)(1); and c. The report in subsection (I)(2);

evidence: Based on interview and documentation review, according to A.R.S. \'a7 13-3620, the administrator had a reasonable basis to believe abuse, neglect, or exploitation had occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, and failed to document the suspected abuse; any action taken according to subsection (I)(1); and the report in subsection (I)(2), for one of two residents sampled. The deficient practice posed a risk as a peace officer, the department of child safety, or a tribal law enforcement was unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the behavioral health residential facility.

findings: A.R.S. \'a7 13-3620 Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted upon the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the Department of Child Safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only ... For the purposes of this subsection, "person" means: Any other person who has responsibility for the care or treatment of the minor. 1. In a joint interview E6 reported around August 2, 2024, R2's grandmother reported possible verbal abuse against R2 by E3 to Julie. E1 stated an internal investigation was conducted and no evidence of abuse was found. Therefore, no report was made to a peace officer, to the Department of Child Safety, or to a tribal law enforcement or social services agency for any Indian minor who resided on an Indian reservation the facility 2. In a joint interview, E1 and E6 reported R2's high needs case manager and R2's mother were included in the conversations held surrounding the alleged verbal abuse against R2. 3. The Compliance Officer requested to review documentation of the suspected abuse, action taken, and the report. However, the documentation was not provided for review. 4. In a joint interview, E1 and E6 acknowledged the suspected abuse was not documented per the Rule.


summary: Compliance (Annual) - 10/11/2023

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 11, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


facility_name: NEW HOPE OF ARIZONA INC

summary: Compliance (Annual) - 3/26/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 26, 2026.


summary: Compliance (Annual) - 3/26/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 26, 2025.


summary: Complaint;Compliance (Annual) - 2/23/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00206694 conducted on February 23, 2024.

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: m. Cover medical records, including electronic medical records;

evidence: Based on documentation review and interview, the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover electronic medical records. The deficient practice posed a risk as policies and procedure reinforces and clarifies standards expected of employees.

findings: 1. A review of facilities policies and procedures revealed no policies and procedures to cover electronic medical records were available for review. 2. In an interview, E1 acknowledged the facility maintained electronic personnel and resident records. E1 acknowledged the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover electronic medical records.

rule: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on record review, documentation review, and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury or had an accident requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to other residents of the facility.

findings: 1. A review of R2's medical record revealed a document titled "Youth Incident Report" dated January 31, 2024. The report stated, "...The member was screaming and yelling no one cared and to stay away. Member then started scratching horizontally with a piece of glass on their forearm... Member was taken to Mind 24/7 via EMT..." On February 1, 2024, an incident report stated, "... Member exhibited and indicated suicidal ideation behaviors ... member began scratching at their scars from previous incident... Member was evaluated at [hospital] for psychiatric inpatient. It was determined the member met criteria and was admitted due to DTS/DTO Behaviors." 2. A review of R4's medical record revealed a document titled "Youth Incident Report." The report stated, "... Writer found fresh blood on a tissue on the master bathroom floor... Writer conducted a contraband search in the master bedroom. Writer found a spiral notebook behind [R4] bed with wire sticking out. [R4] was crying and admitted to self harming with the metal object because [R4] didn't want to be there." 3. A review of facility documentation revealed no written notification to the Department of R2's or R4's self-injuries, within two working days after inflicting a self-injury or had an accident requiring immediate intervention by an emergency medical services provider. 4. In an interview, E1 acknowledged R2's and R4's medial records revealed incidents of self harm. E1 acknowledged the Department was not provided written notification of R2's or R4's self-injury, within two working days after R2 and R4 inflicted a self-injury or had an accident requiring immediate intervention by an emergency medical services provider.

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 2. Report the suspected abuse, neglect, or exploitation of the resident: b. For a resident under 18 years of age, according to A.R.S. § 13-3620;

evidence: Based on documentation review and interview, the administrator failed to report suspected abuse, neglect, or exploitation of a resident under 18 years of age according to A.R.S. \'a7 13-3620. The deficient practice posed a health and safety to residents as the facility had a reasonable basis to believe abuse had occurred on the premises, and it was not reported per A.R.S. \'a7 13-3620.

findings: 1. A.R.S. \'a7 13-3620.A states "A. Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only..." 2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay." 3. A review of the facility's documentation revealed an incident report dated January 30, 2024. The incident report stated " I [E2] arrived at Watkins at 10:00 pm. When conducting a room check, I found [R1] sitting on bed crying... [R1] said, at around 6:00 pm on 01/30/2024 [R1's] peer inappropriately touched [R1's] butt, as [R1] was walking down the hallway at the Watkins home. Youth said, [R1] moved and [R2] touched [R1's] butt a second time. The morning of 01/31/24, at 7:40 am, [R2] admitted to [E2] that [R2] touched [R1] on the butt. Persons Notified [E3] 1/30/24, at 11:00 pm, Guardian 1/30/24 at 10:55 pm, Referring Agency Case Manager 1/31/24, at 9:30 am, Police January 31, 2024, at 11:40 am, DCS 1/30/2024, at 9:30 am." 4. In an interview, E2 reported E2 called the house manager E3 and reported the allegations immediately on January 30, 2024. E2 reported that E2 did not believe any additional providers were contacted until the following day January 31, 2024. E2 reported E2 had no knowledge of the reporting requirements according to A.R.S. \'a7 13-3620. 5. In an interview, E1 acknowledged the incident that occurred on January 30, 2024, involving R1 and R2 had not been reported according to A.R.S. \'a7 13-3620. E1 acknowledged the incident report reflected DCS was contacted January 30, 2024, at 9:30 a.m., however this was prior to the incident occurring. E1 acknowledged the incident report reflected a documentation error and DCS was contacted on January 31, 2024, at 9:30 a.m. E1 acknowledged the administrator had reason to believe a minor had been a victim of abuse and failed to immediately report the abuse according to the reporting requirements according to A.R.S. \'a7 13-3620.

rule: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(7) was submitted, and c. Date of the report; and

evidence: Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. The deficient practice posed a risk if this information was required to be reviewed under R9-10-704.

findings: 1. A review of R4's medical record revealed incident reports of unauthorized absences on January 20, 2024, January 13, 2024, and January 8, 2024. 2. The Compliance Officer requested to review the facility's written log of unauthorized absences. However, a written log of unauthorized absences was not provided for review. 3. In an interview, E1 reported a written log of unauthorized absences was not available for review.

rule: A. An administrator shall ensure that: 1. A resident is admitted based upon: b. The resident's behavioral health issue and treatment needs are within the behavioral health residential facility's scope of services;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services. The deficient practice posed a risk as a resident was admitted into a behavioral health residential facility who required a higher level of care.

findings: 1. A review of the facility policies and procedures revealed their scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling for individuals who do not require on site medical services..." 2. A review of R2's medical record revealed a behavioral health assessment completed prior to R2's admission dated in October 2023. R2's assessment identified the following information, "...Risk/History of Suicide Attempts?: Yes, client overdosed about a week ago on prescription meds. Attempted to hang self 2 x with a shower curtain, 2 years ago attempted to cut throat with glass. Current suicidal ideation, intent, plans, or access to means?: Yes, client denied any current intent or plan but said SI are still present." A review of R2's medical record revealed a signed attestation reviewing the identified behavioral health assessment on November 14, 2023 signed by facilities behavioral health professional. The attestation reflected "No Update." 3. In an interview, E1 acknowledged the identified documents were included in R2's admission documentation. E1 acknowledged the October 2023, document identified R2's current concern of being a danger to self. E1 acknowledged the administrator failed to ensure a resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services.

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination on a resident within 30 calendar days before admission or within 72 hours after admission, for one of four residents 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 R2's electronic medical record revealed documentation of a medical history and physical examination was completed six days after R2's admission. 2. In an interview, E1 acknowledged R2's documentation of a medical history and physical examination or a nursing assessment was not completed within 30 calendar days before admission or within 72 hours after admission.

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 a behavioral health assessment 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 the behavioral health assessment identified the behavioral health services needed by the resident. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services to determine which services a health care institution would provide was not completed within 24 hours.

findings: 1. A review of R3's medical record revealed a behavioral health assessment completed by E3, a BHT. The assessment revealed a BHP had not reviewed and signed the behavioral health assessment. 2. In an interview, E1 reviewed R3's behavioral health assessment. E1 acknowledged the assessment was completed by a BHT and did not include documentation a BHP reviewed and signed the behavioral health assessment.

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. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of R2's medical record revealed documentation a TB test had been administered. However, documentation of the TB test result and freedom from infectious TB was completed nine days after admission. 2. In an interview E1 acknowledged R2 did not provide evidence of freedom from infectious TB before or within seven calendar days after R2's admission.

rule: 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 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 which affected treatment. The deficient practice posed a risk as a treatment plan directs the service to be provided to a resident.

findings: 1. A review of R1's medical record revealed an incident report dated January 30, 2024, identifying allegations of abuse by another resident towards R1 at the facility. A review of R1's treatment plan revealed R1's treatment plan was not updated after the identified significant event. 2. A review of R4's medical record revealed incident reports of self harm and absences without leave from the facility occurring in January 2024. A review of R4's treatment plan revealed R4's treatment plan was not updated after these identified significant events. 3. In an interview, E1 acknowledged R1 and R4 experienced significant incidents affecting their treatment. E1 acknowledged the administrator failed to ensure a treatment plan was updated when R1 and R4 had a significant change in condition or experience which affected R1's or R4's treatment.

rule: G. An administrator shall ensure that a discharge summary for a resident: 1. Is entered into the resident's medical record within 10 working days after a resident's discharge; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a discharge summary for a resident was entered into the resident's medical record within 10 working days after a resident's discharge.

findings: 1. A review of R2's medical record revealed a discharge summary was completed twelve days after R2's discharge. 2. In an interview, E1 reviewed R2's electronic medical record. E1 acknowledged R2's medical record did not contain documentation of a discharge summary entered into the resident's medical record within 10 working days after a resident's discharge.

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;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure, if a behavioral health residential facility was 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 received continuous protective oversight. The deficient practice posed a risk to residents who required continuous protective oversight due to being minors under the age of 18.

findings: 1. A review of R2's medical record revealed a document titled "Youth Incident Report" dated January 31, 2024. The report stated, "... The member was screaming and yelling no one cared and to stay away. Member then started scratching horizontally with a piece of glass on their forearm... Member was taken to Mind 24/7 via EMT..." On February 1, 2024, an incident report stated, "... Member exhibited and indicated suicidal ideation behaviors... member began scratching at their scars from previous incident... Member was evaluated at [hospital] for psychiatric inpatient. It was determined the member met criteria and was admitted due to DTS/DTO Behaviors." 2. A review of R4's medical record revealed a document titled "Youth Incident Report." The report stated, "...Writer found fresh blood on a tissue on the master bathroom floor...Writer conducted a contraband search- in the master bedroom. Writer found a spiral notebook behind [R4] bed with wire sticking out. [R4] was crying and admitted to self harming with the metal object because they didn't want to be there." A review of R4's medical record revealed incident reports of unauthorized absences from the behavioral health facility on January 20, 2024, January 13, 2024, and January 8, 2024. 3. In an interview, E1 reviewed the identified incident reports. E1 acknowledged the facility was licensed to provide behavioral health services to individual who behavioral health issues limit their ability to function independently. E1 acknowledged the incident reports revealed R2 and R4 were not provided continuous protective oversight.

rule: A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a resident did not share a space with another resident which may have presented a threat to the resident's health or safety, based on the other resident's documented diagnoses, treatment needs, and personal history. Finding: 1. A review of R1's medical record revealed a documented history of sexual abuse. 2. A review of the facility's documentation revealed an incident report dated January 30, 2024. The incident report stated: "[E2] arrived at Watkins at 10:00 pm. When conducting a room check, I found [R1] sitting on bed crying.... [R1] said, at around 6:00 pm on 01/30/2024 [R1's] peer inappropriately touched [R1's] butt, as [R1] was walking down the hallway at the Watkins home. Youth said, [R1] moved and [R2] touched [R1's] butt a second time. The morning of 01/31/24, at 7:40 am, [R2] admitted to [E2] that [R2] touched [R1] on the butt. Persons Notified [E3] 1/30/24, at 11:00 pm, Guardian 1/30/24 at 10:55 pm, Referring Agency Case Manager 1/31/24, at 9:30 am, Police January 31, 2024, at 11:40 am, DCS 1/30/2024, at 9:30 am. " 3. In an interview, E2 reported R1 and R2 shared a bedroom. E2 reported no action was taken after the reported incident to remove R1 and R2 from the same bedroom. E2 reported R1 eventually returned to R1's and R2's room to sleep the evening of the incident. E2 reported in the morning all of the residents ate breakfast together. E2 reported E2 was the only staff present at the facility. 4. In an interview, E1 acknowledged R1 and R2 shared a space which presented a threat to R1's health and safety based on R1's personal history.

rule: 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: a. The date and time the emergency safety response was used; b. The name of each personnel member who used an emergency safety response; c. The specific emergency safety response used; d. The personnel member or resident behavior, event, or environmental factor that caused the need for the emergency safety response; and e. Any injury that resulted from the use of the emergency safety response;

evidence: Based on record review and interview, the administrator failed to ensure within 24 hours after an emergency safety response (ESR) was used for a resident, the following information was entered into the resident medical record: the date and time the ESR was used, the name of each personnel member who used an ESR, the specific ESR used, the personnel member or resident behavior, event, or environmental factor that caused the need for the ESR, and any injury that resulted from the use of the ESR.

findings: 1. A review of R2's medical record revealed an incident report dated February 1, 2024 and completed on February 3, 2024. The incident report stated " [R2] exhibited and indicated suicidal ideation behaviors after returning to the home...[R2] became physically aggressive with the writer...Writer instantly placed the member in a children control position for 2 minutes. Member continued trying to swing. Writer placed member in another children's control position hold for 2 minutes." A review of R2's medical record revealed no additional documentation of the ESR. 2. In an interview, E1 confirmed an ESR was used for R2 on February 1, 2024. E1 acknowledged the documented report was not completed until February 3, 2024. E1 acknowledged the required information was not documented related to the ESR.

rule: B. An administrator shall ensure that: 1. A behavioral health residential facility has a: a. Room that provides privacy for a resident to receive treatment or visitors; and

evidence: Based on observation and interview, the administrator failed to ensure the behavioral health residential facility had a room to provide privacy for a resident to receive treatment or visitors. The deficient practice posed a risk if the administrator was unable to ensure confidentiality in treatment as well as a resident's right to privacy in treatment and visitation.

findings: 1. The Compliance Officer observed no privacy room available. The Compliance Officer observed an office with a posting which stated "Watkins Office Staff Only." The office contained paint in an unlocked closet shelf and disinfectant wipes on the desk. 2. In an interview, E2 reported the residents received visitors or counseling at the dining room table or in their individual rooms. E2 reported that if a resident shares a room, the other residents are asked to leave. E2 reported the office is not used for visitation. 3. In an interview, E1 reported the "Watkins Office Staff Only" room is identified by the facility to provide privacy for residents to receive treatment or visitors. E1 acknowledged E2 reported E2 was unaware of this. E1 acknowledged the room contained toxic chemicals that would be accessible to residents using the room for treatment or visitors. E1 acknowledged the behavioral health residential facility did not have a room to provide privacy for a resident to receive treatment or visitors.


summary: Complaint;Compliance (Annual) - 5/12/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00195028 and AZ00188352, conducted on May 12, 2023:

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and c. Is maintained for at least 12 months after the last date on the documentation;

evidence: Based on observation, documentation review, observation, and interview, the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee.

findings: 1. The compliance officer observed E2 working at the facility at the time of the inspection. 2. A request of the facility's staffing schedule revealed a current schedule dated May 7, 2023 through May 13, 2023. The schedule revealed no documentation of the name of the employee assigned to work including on-call for the hours of 9 am to 2 pm.. The schedule for May 9, 2023, May 10, 2023, and May 11, 2023, revealed only the date, work hours and name of the employee working 2 pm to 11:30 pm. The personnel schedule for May 12, 2023, revealed only the date, work hours and name of the employee working 2 pm to 10 pm and 10 pm to 12 am. The personnel schedule did not identify E2 working at the facility on May 12, 2023. 3. In an interview, E1 acknowledged the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, and included documentation of the employees who worked each calendar day and the hours worked by each employee.

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

evidence: Based on documentation review, record review, observation, and interview, the administrator failed to ensure a resident did not 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.

findings: 1. A review of R1's medical record revealed a behavioral health assessment. The assessment identified R1 has a history of self harm. 2. A review of R1's medical record revealed an incident report dated March 14, 2023. The incident report stated "One of the peers went into the lock box located in the office and took the chemical cleaning product Bar Keeper. Original canned scouring powder product. They poured the powder into a small container and kept it in their room. Their peers were snorting the cleaning product. The member informed the DSP where the item was being stored in their room....DSP contacted Poison Control. The incident report identified no further medical evaluations were required. 3. In an interview E1 reported R1 gained access to a chemical cleaning product stored by the facility and ingested the cleaning product. E1 acknowledged the administrator failed to ensure R1 did not 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.


summary: Compliance (Annual) - 8/26/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on August 26, 2025.


summary: Compliance (Annual) - 8/28/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on August 28, 2024.

rule: E. A resident has the following rights: 3. To receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent, except: a. A resident may be photographed when admitted to a behavioral health residential facility for identification and administrative purposes;

evidence: Based on observation and interview, the administrator failed to ensure a resident received privacy in treatment. The deficient practice posed a risk as the administrator did not ensure confidentiality in treatment as well as a resident's right to privacy in treatment.

findings: 1. The Compliance Officer observed the facility identified an opened loft area at the front of the residential facility and an office/privacy room available for residents for privacy in treatment and visitation. 2. In an interview, R1 reported R1 received counseling in the open loft room while other residents were present in the facility living room. 3. In a phone interview, E3 acknowledged E3 provided counseling in the open loft area due to E3 having Internet connectivity issues in the identified privacy room. 4. In an interview, E1 acknowleged the administrator to ensure confidentiality in treatment as well as a resident's right to privacy in treatment.

rule: B. An administrator shall ensure that: 6. If a resident bathroom door locks from the inside, an employee has a key and access to the bathroom;

evidence: Based on observation and interview, the administrator failed to ensure an employee had a key and access to a bathroom with a door capable of being locked from the inside.

findings: 1. The Compliance Officer observed a resident shared bathroom which contained a door lockable from the inside. 2. The Compliance Officer requested E1 to demonstrate the bathroom door could be unlocked. E1 was unable to demonstrate the bathroom door could be unlocked. E1 acknowledged an employee could not gain access to the bathroom which contained a door lockable from the inside. 3. In an interview, E2 acknowledged the administrator failed to ensure an employee had a key and access to a bathroom with a door capable of being locked from the inside.


summary: Complaint - 2/23/2024

raw_content: An on-site investigation of complaint AZ00206774 was conducted on February 23, 2024 and the following deficiency was cited :

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: a. Provide the services in the behavioral health residential facility's scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.

evidence: Based on observation, documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk if the facility was unable to meet the needs of the residents and ensure the resident's health and safety.

findings: 1. The Compliance Officer observed R1 at BH4629 at 9:20 AM on February 23, 2024. 2. A review of the facilities staffing schedule for February 23, 2024, revealed no personnel member identified as working at the facility from 9:00 AM to 10:30 AM. 3. In an interview, E1 reported E1 received a phone call at 9:25 AM asking E1 to work. E1 reported E1 was on-call. 4. In an interview, R1 reported R1 was a resident of BH4630. R1 acknowledged E3 transported R1 to BH4629. R1 reported R1 remained at BH4629 until R1 was picked up by E1. 5. In an interview, E2 reported E3 brought R1, the only resident not scheduled to be in school, to BH4629 when E3's shift ended. E1 reported the facility believed R1 could remain at the other licensed facility. E1 acknowledged sufficient personnel members were not present at the behavioral health residential facility's premises to meet the needs of R1.


summary: Compliance (Annual) - 9/19/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on September 19, 2023.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. Equipment used at the behavioral health residential facility is: a. Maintained in working order;

evidence: Based on observation, and interview, the administrator failed to ensure equipment used at the behavioral health residential facility was maintained in working order.

findings: 1. The Compliance Officer observed the facilities kitchen contained a microwave with no door. The microwave was not maintained in working order. 2. In an interview, E2 reported the microwave was broken. E2 acknowledged equipment used at the behavioral health residential facility was not maintained in working order.


facility_name: DEVEREUX ARIZONA - CASA VALOR

summary: Complaint - 3/20/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint  00136750 and 00104700 conducted on March 20, 2026:


summary: Compliance (Annual) - 10/24/2024

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2022 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee 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: Compliance (Annual) - 9/6/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2022 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of September 1, 2023 through August 31, 2024, 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: Compliance (Annual) - 4/14/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of September 1, 2022 through August 31, 2023, 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.


facility_name: ZAREPHATH APACHE HOUSE

summary: Compliance (Annual) - 7/18/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on July 18, 2025:

rule: A.R.S. § 36-420.01.A. 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.

evidence: Based on documentation review and interview, the health care institution failed to develop a training program regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed.

findings: 1. A review of facility documentation revealed no training program for fall prevention and fall recovery. 2. In an interview, E1 reported policies and procedures were developed regarding fall prevention and fall recovery. However, E1 was unable to locate the policies and procedures. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were 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 documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of clinical oversight, as required in Arizona Administrative Code (A.A.C.) R9-10-115, for one of one personnel members sampled who provided counseling. The deficient practice posed a risk as a behavioral health technician provided behavioral health services they were not licensed to provide and were without clinical oversight by a licensed behavioral health professional.

findings: A.A.C. R9-10-101.49.a.b.c.d. "Clinical oversight" means: Monitoring the behavioral health services provided by a behavioral health technician to ensure that the behavioral health technician is providing the behavioral health services according to the health care institution's policies and procedures and, if applicable, a patient's treatment plan; Providing on-going review of a behavioral health technician's skills and knowledge related to the provision of behavioral health services; Providing guidance to improve a behavioral health technician's skills and knowledge related to the provision of behavioral health services; and Recommending training for a behavioral health technician to improve the behavioral health technician's skills and knowledge related to the provision of behavioral health services. A.A.C. R9-10-115(4) A behavioral health technician receives clinical oversight at least once during each two-week period, if the behavioral health technician provides services related to patient care at the health care institution during the two-week period. 1. A review of R1's and R2's medical records revealed E5 had provided group counseling to R1 and R2 in March 2025. 2. A review of E5's electronic personnel record revealed no documentation of clinical oversight. 3. In an interview, E1 reported E5 received clinical oversight and was unsure why E5's documentation was not in E5's personnel record. 4. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

rule: R9-10-706.G.3.j. 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: j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.A.B., for one of seven personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113(A)(2)(b) states: "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: Referring the individual for assessment or treatment; and 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." R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), 1. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (pre-placement), two-step testing should be used." 2. A review of E7's electronic personnel record revealed documentation of a single negative TST dated in July 2023, "TB HEALTHCARD" and chest x-ray dated in November 2023. However, E7's electronic personnel record revealed no documentation of the recommended two-step TST. 3. In an interview, E1 reported to be unaware the "TB HEATHCARD" was not in compliance in R9-10-113. 4. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

rule: R9-10-708.A.1. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 1. Is based on the medical history and physical examination or nursing assessment required in R9-10-707(A)(6) or (E)(1)(a) and the behavioral health assessment required in R9-10-707(A)(9) or (10) and on-going changes to the behavioral health assessment of the resident;

evidence: Based on record review and interview, the administrator shall ensure a treatment plan was developed and implemented for each resident based on the nursing assessment required in R9-10-707(A)(6) or (E)(1)(a) for two of two medical records sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements based on the medical history and physical examination or nursing assessment.

findings: A.R.S. § 36-425.08(A) A behavioral health residential facility may provide respite care to a child for increments of fewer than five consecutive days and not more than twelve days in a ninety-day period or an outpatient clinic may provide respite care to a child for up to ten continuous hours per day between the hours of 6:00 a.m. and 10:00 p.m. without a medical history and physical examination. 1. A review of R1's (last admitted in 2025) electronic medical record revealed a treatment plan dated in December 2024. However, a review of R1's electronic medical record revealed no documentation of a nursing assessment required in R9-10-707(A)(6) or (E)(1)(a), and therefore, the treatment plan was not based on the nursing assessment. 2. A review of R2's (last admitted in 2025) electronic medical record revealed a treatment plan dated in January 2025. However, a review of R2's electronic medical record revealed no documentation of a nursing assessment required in R9-10-707(A)(6) or (E)(1)(a), and therefore, the treatment plan was not based on the nursing assessment. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

rule: R9-10-712.C.9. Medical Records C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained orders, for two of two medical records sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's and R2's (last admitted in 2025) electronic medical records revealed no documentation of medication orders. 2. A review of R1's electronic medical record revealed a medication administration record dated in March 2025 for the following medication: -"Amphetam / Dextoamp ER 10mg 1 capsule @ 8 am." However, E1's electronic record revealed no documentation of medication orders. 3. A review of R2's electronic medical record revealed a medication administration record dated in March 2025 for the following medications: -"Clonidine HCL .1mg tab 2 tabs @ 8 pm;" and -"Atomoxetine HCL 18 mg cap 1 cap @ 8 am." However, R2's electronic record revealed no documentation of medication orders. 4. In an interview, E1 reported E1 has requested the signed medication orders in the past but had not received the orders. 5. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.

rule: R9-10-716.B.2. Behavioral Health Services B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan, for two of two medical records sampled. The deficient practice posed a risk if a resident did not receive sufficient treatment to cure, improve, or palliate their behavioral health issues.

findings: 1. A review of R1's (last admitted in 2025) electronic medical record revealed a treatment plan dated in December 2024. The treatment plan stated "...Group counseling (Respite) (1-6x/Quarter)." However, the treatment plan did not include the number of hours for group therapy to be provided to R1. 2. A review of R2's (last admitted in 2025) electronic medical record revealed a treatment plan dated in January 2025. The treatment plan stated "...Group counseling (Respite) (1-6x/Quarter)." However, the treatment plan did not include the number of hours for group therapy to be provided to R1. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or documentation were provided.


summary: Compliance (Annual) - 3/12/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 12, 2024. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


facility_name: NEW HOPE OF ARIZONA, INC

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

raw_content: No deficiencies were found during the on-site compliance inspection conducted on December 17, 2025.


summary: Compliance (Annual) - 12/10/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on December 10, 2024:

rule: B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan, for two of two respite residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed a treatment plan dated February 27, 2024. The treatment plan stated, "...Group Therapy a minimum of 1x every 6 months...." A review of R1's medical record revealed no documentation of counseling provided to R1. 2. A review of R2's medical record revealed treatment plans dated December 21, 2023, and November 7, 2024. The treatment plans stated, "...Group Therapy a minimum of 1x every 6 months..." A review of R2's medical record revealed no documentation of counseling provided to R2. 3. In an interview, E1 reviewed R1's and R2's medical records. E1 acknowledged R1's and R2's medical record failed to include counseling.


summary: Compliance (Annual) - 12/6/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 6, 2023:

rule: A. An administrator shall ensure that: 5. Behavioral health services listed in the behavioral health residential facility's scope of services are provided on the premises;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services listed in the behavioral health residential facility's scope of services were provided on the premises. The deficient practice posed a risk if the residents admitted to the residential facility did not receive the behavioral health services expected to be provided on the premises.

findings: 1. A review of the facility policies and procedures revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R1's and R2's treatment plans revealed no documentation of counseling identified in the residents medical record. 3. In an interview, E1 reported the identified facility residents receive respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services were not provided on the premises.


facility_name: ZAREPHATH YUMA HOUSE

summary: Compliance (Annual) - 1/12/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 12, 2026.


summary: Compliance (Annual) - 9/6/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on September 6, 2024:

rule: 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: t. Cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure policies and procedures for behavioral health services were established and documented to protect the health and safety of a resident to cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

findings: 1. A review of the facility's policies and procedures revealed a policy and procedure to cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual was not available for review. 2. In an interview, E1 reported the facility did not have a policy and procedure regarding covering how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.


facility_name: MATTIES CARE HOUSE LLC

summary: Modification - 12/9/2025

raw_content: An off-site review of documentation to decrease the occupancy from ten (10) to nine (9) was completed on December 9, 2025.

inspection_type: Modification


summary: Complaint - 11/18/2025

raw_content: No deficiencies were found during the on-site investigation of complaints 00150094 and 00150730  conducted on November 18, 2025.


summary: Complaint - 10/9/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaints 00146214 and 00146377 conducted on October 9, 2025:

rule: A.R.S. § 36-407.A. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining. The license is valid only for the establishment, operation and maintenance of the class or subclass of health care institution, the type of services and, except for emergency admissions as prescribed by the director by rule, the licensed capacity specified by the license.

evidence: Based on observation, documentation review and interview, the administrator failed to maintain a health care institution within the licensed capacity of 10 residents. The deficient practice posed a risk if the Department was unable to assess and approve an increased occupancy, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of Department documentation revealed BH4867 was approved for a licensed capacity of ten (10) residents (effective February 7, 2023.) 2. The Compliance Officer observed twelve (12) residents on the premises when the Compliance Officer arrived at 11:15AM. 3. The Compliance Officer observed two behavioral health technicians, E2 and E3, working on the premises when the Compliance Officer arrived at 11:15AM. 4. In an interview, R11 stated R11 was a resident at BH8438 but had slept at BH4867 for the last week, during fall break. R11 reported R11 slept on the floor, on an air mattress, in the bedroom with two beds. 5. In an interview, R12 stated R12 was a resident at BH8438 but had slept at BH4867 for "a few nights." R12 reported R12 slept in R1's bed because R1 had been sleeping on the couch downstairs due to R1 having a broken arm and being unable to climb up into R1's assigned bunk bed. 6. In an interview, E2 reported BH4867 had a census of 10 residents. E2 reported R11 and R12 were residents at BH8438 and were visiting BH4867 for the day to do an outing with the residents at BH4867. 7. In an exit interview, E1 acknowledged the facility failed to maintain the health care institution within the licensed capacity of 10 residents. E1 reported R11 and R12 were residents at BH8438 and reported R11 and R12 had slept at BH4867, putting the licensed capacity over 10. E1 reported R11 slept on the couch and R12 slept in R1's bed. This is a repeat violation from the complaint investigation conducted on January 2, 2024.

rule: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on observation and interview, the administrator failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk as the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. The Compliance Officer observed twelve (12) residents on the premises when the Compliance Officer arrived at 11:15AM. 2. In an interview, R11 stated R11 was a resident at BH8438 but had slept at BH4867 for the last week, during fall break. R11 reported R11 slept on the floor, on an air mattress, in the bedroom with two beds. 3. In an interview, R12 stated R12 was a resident at BH8438 but had slept at BH4867 for "a few nights." R12 reported R12 slept in R1's bed because R1 had been sleeping on the couch downstairs due to R1 having a broken arm and being unable to climb up into R1's assigned bunk bed. 4. In an exit interview, E1 acknowledged the residents were not treated with dignity, respect and consideration because the facility was overcapacity and R1 was not provided a bed. This is a repeat violation from the complaint investigation conducted on July 31, 2024.


summary: Complaint;Compliance (Annual) - 9/9/2025

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaints 00142474, 00142819 and 00143489 conducted on September 9, 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 five personnel members sampled. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of E2's (hired in 2024) personnel record revealed one negative TB skin test, read on July 29, 2024. However, a second TB skin test was not provided for review. 2. In an interview, E1 acknowledged E2 did not have a two step TB test completed.


summary: Complaint - 10/30/2024

raw_content: An on-site investigation of complaint AZ00218099 was conducted on October 30, 2024 and no deficiencies were cited.


summary: Complaint;Compliance (Annual) - 8/23/2024

raw_content: This new Statement of Deficiencies supercedes the Statement of Deficiencies sent to the licensee on September 17, 2024. The following deficiencies were found during the on-site compliance inspection and investiation of complaint AZ00214436 conducted on August 23, 2024:

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

evidence: Based on documentation review and interview, the administrator failed to ensure documentation required by Article 7 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. The Compliance Officer arrived at the facility at 9:45 AM. 2. The Compliance Officer requested, at 10:15 AM, the following documentation for review: -Disaster drills for the last 12 months 3. In an interview, at 1:10 PM, E1 acknowledged the aforementioned documentation had not been provided within two hours after a Department request.

rule: E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or physical health services;

evidence: Based on record review and interview, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services, for one of five personnel members sampled. The deficient practice posed a risk if E5 was unable to meet the needs of the residents.

findings: R9-10-101.153. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of E5's (hired in 2024) personnel record revealed documentation to demonstrate E5 had been oriented to the facility was not availble for review. 2. In an interview, E1 acknowledged E5 had not received orientation.

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 the daily staffing schedule for August 2024 revealed the facility maintained the following shifts: -1st shift - 8:00 AM - 4:00 PM -2nd shift - 4:00 PM - 12:00 AM -3rd shift - 12:00 AM - 8:00 AM 2. A review of facility documentation revealed the following disaster drills were completed and documented: -September 6, 2023 - 1st shift -September 15, 2023 - 3rd shift -September 16, 2023 - 2nd shift -December 1, 2023 - 2nd shift -December 16, 2023 - 1st shift -December 23, 2023 - 3rd shift -March 9, 2024 - 1st shift -March 9, 2024 - 2nd shift -March 21, 2024 - 3rd shift 3. In an interview, E1 acknowledged disaster drills were not conducted on each shift at least once every three months. E1 reported E1 was fairly sure the drills had been done but acknowledged E1 was unable to provide the disaster drill documentation for review.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: b. Is not used as a passageway to another bedroom or bathroom unless the bathroom is for the exclusive use of an individual occupying the bedroom;

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom was not used as a passageway to another bedroom or bathroom. The deficient practice posed a possible resident rights violation.

findings: 1. The Compliance Officer observed the master bedroom, with four sets of bunkbeds, contained a master bathroom. The master bathroom contained a locked closet and contained cleaning supplies used by personnel members. 2. In an interview, E1 reported to be unaware the master bedroom could not be used as a passageway by personnel members to the bathroom.


summary: Complaint - 7/31/2024

raw_content: An on-site investigation of complaint AZ00213863 was conducted on July 31, 2024 and the following deficiencies were cited:

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: n. Cover a quality management program, including incident reports and supporting documentation;

evidence: Based on interview, documentation review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover a quality management program, including incident reports and supporting documentation. The deficient practice posed a risk as the facility's standards were not followed.

findings: 1. In an interview, E1 acknowledged investigations by Arizona Healthcare Cost Containment System and the Arizona Department of Health into allegations of a lack of food at the licensed facility within the previous month. 2. A request was made for the incident report, grievance or investigation into these allegations. None could be provided by the exit survey. 3. A request was made for a policy on investigations care concerns. A policy was produced titled "Grievance Policy" last reviewed on February 6, 2024, which revealed "...Any complaint, concern, or dispute rendered by a Provider, Client, Client Family, or staff member is considered a grievance...If/when a grievance form is submitted to MCH (Matties Care House)...management will contact the concerned party to address the claim within 48 hours...." 4. Another policy was produced titled "Policy Implementation I. Encouragement of Reporting; Reporting Obligation" last reviewed on February 6, 2024, which revealed "...Mattie's Care House LLC (MCH) encourages employees of its community to report all information regarding any activity they reasonable believe to be wrongful or unlawful...circumstances of substantial, specific, or imminent danger to...students...safety; suspected child abuse and/or neglect...." 5. Another policy was produced titled "Reporting and Investigation Process" last reviewed on February 6, 2024, which revealed "...Reporting...Reports should be made as promptly as possible after the suspected wrongful or unlawful activity...occurs in order to facilitate investigation of the report. All reports will be handled as promptly and discreetly as possible, with facts made available only to those who need to know to investigate and resolve the matter...." 6. In an interview, E1 acknowledged no investigation, grievance, or incident report was created or documented by the licensed facility based on the multiple investigations by outside agencies regarding resident food concerns in the previous month.

rule: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on observation, documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk as residents' rights were violated.

findings: 1. Observation while on site revealed a prospective employee enter the licensed facility for an interview. The prospective employee walked past the residents who were in the living room and a table was set up in the dining room for an interview. Residents were in an out of the kitchen walking past the living room in plain sight of the prospective employee while starting the interview process. 2. A policy was requested on privacy in treatment. A policy was produced titled "Rights for Children" last reviewed on February 6, 2024, which revealed "...The following list of rights is not all-inclusive and is not meant to limit the rights of our clients that are guaranteed under State and Federal laws...The right to privacy including during treatment and care of personal needs...." 3. In an interview, E1 acknowledged the living room of the licensed facility was not an area where an interview with a prospective employee should have been conducted while residents were present. 4. In an interview, E1 acknowledged residents have a right to privacy while in treatment.


summary: Complaint - 7/22/2024

raw_content: An on-site investigation of complaint AZ00213295 and AZ00213310 was conducted on July 22, 2024 and no deficiencies were cited :


summary: Complaint - 7/15/2024

raw_content: An on-site investigation of complaint AZ00212975 was conducted on July 15, 2024 and no deficiencies were cited :


summary: Complaint - 6/5/2024

raw_content: An on-site investigation of complaint AZ00211174 was conducted on June 5, 2024 and no deficiencies were cited :


summary: Complaint - 5/29/2024

raw_content: An on-site investigation of complaint AZ00210895 was conducted on May 29, 2024 and no deficiencies were cited :


summary: Complaint - 4/5/2024

raw_content: An on-site investigation of complaint was conducted on April 5, 2024. No deficiencies were cited :


summary: Complaint - 1/23/2024

raw_content: An on-site investigation of complaint AZ00205479 was conducted on January 23, 2024 and no deficiencies were cited :


summary: Complaint - 1/10/2024

raw_content: An on-site investigation of complaint AZ00204923 was conducted on January 10, 2024 and the following deficiency was cited:

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 b. According to policies and procedures; and

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided behavioral health services, for one of five behavioral health technicians sampled. The deficient practice posed a risk if E6 was unable to meet a resident's needs.

findings: 1. A review of facility documentation revealed a daily staffing schedule, titled "January 2024." The daily staffing schedule revealed E6 was scheduled to work on the following dates: -January 1, 2024 - 12 AM - 8 AM -January 3, 2024 - 12 AM - 8 AM -January 5, 2024 - 12 AM - 8 AM -January 6, 2024 - 12 AM - 8 AM -January 7, 2024 - 12 AM - 8 AM -January 8, 2024 - 12 AM - 8 AM 2. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician. A document, titled "MCHL New Hire Skills and Knowledge Verification Checklist," was in E6's personnel record. However, the document was blank. 3. In an interview, E1 acknowledged skills and knowledge had not been verified for E6 prior to E6 providing behavioral health services. E1 acknowledged E6 had worked approximately six shifts in the facility.