summary: Complaint - 1/2/2024

raw_content: An on-site investigation of complaints AZ00202948 and AZ00204650 was conducted on January 2, 2024 and the following deficiencies were cited :

rule: A.R.S. § 36-407. 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.

findings: 1. The Compliance Officer observed 14 residents on the premises when the Compliance Officer arrived at 9:15AM. 2. The Compliance Officer observed one behavioral health technician, E2, alone and working on the premises when the Compliance Officer arrived at 9:15AM. 3. A review of Department documentation revealed BH4867 was approved for a licensed capacity of 10 residents (effective February 7, 2023). 4. In an interview, E2 reported BH4867 had a census of 9 residents. E2 reported the other 5 residents were from BH8438. E2 reported the residents were getting ready to go to the park. 5. In an interview, E2 reported the personnel member from BH8438 was scheduled to work the day shift. E2 reported a personnel member called in sick at BH8438 and the residents from BH8438 were brought to BH4867. 6. In an interview, E1 reported the personnel member from BH8438 was scheduled to work the day shift. E1 reported a personnel member called in sick at BH8438 and the residents from BH8438 were brought to BH4867. 7. In an interview, E1 acknowledged the facility failed to maintain the health care institution within the licensed capacity of 10 residents.

evidence: Based on documentation review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request.

findings: 1. A review of facility documentation revealed documentation to demonstrate requirements regarding residents entering and exiting the premises was not available for review. 2. In an interview, E1 reported E1 had established and documented requirements regarding residents entering and exiting the premises. However, this documentation was not provided for review. 3. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

rule: K. An administrator shall: 1. Establish and document requirements regarding residents, personnel members, employees, and other individuals entering and exiting the premises;

evidence: Based on documentation review and interview, the administrator failed to establish and document requirements regarding residents entering and exiting the premises.

findings: 1. A review of facility documentation revealed documentation to demonstrate requirements regarding residents entering and exiting the premises was not available for review. 2. In an interview, E1 reported E1 had established and documented requirements regarding residents entering and exiting the premises. However, this documentation was not provided for review. 3. In an interview, E1 acknowledged documentation to demonstrate requirements regarding residents entering and exiting the premises was not available for review

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

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

findings: A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of E5's (hire date unknown) personnel record revealed E5 was hired as a behavioral health technician (BHT). E5's personnel record revealed a valid fingerprint clearance card. However, notarized documentation E5 was not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction was not available for review. 2. In an interview, E1 reported E1 was not able to locate E5's notarized documentation. 3. In an interview, E1 acknowledged E5's personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E).

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e), and first aid training, for one of five behavioral health technicians (BHT) sampled. The deficient practice posed a risk if a BHT was unable to meet a resident's needs during an emergency, accident, or injury.

findings: 1. A review of facility documentation revealed a policy and procedure titled "ARS 36-420.B.3 CARDIOPULMONARY RESUSCITATION (CPR) AND FIRST AID" (dated January 31, 2023). The policy and procedure stated " ... all MCH employees that provide direct support are required to possess and maintain a valid First Aid and CPR/AED certificate as a minimum requirement of their employment." 2. A review of facility documentation revealed daily staffing schedules for December 2023 and January 2024. The schedule revealed at least two behavioral health technicians were scheduled, and E4 was scheduled to work from 12:00AM to 8:00AM on the following dates: -December 1-3, 2023; -December 6, 2023; -December 8-11, 2023; -December 13, 2023; -December 15-18, 2023; -December 20, 2023; -December 22-25, 2023; -December 27, 2023; -December 29-31, 2023; -January 1, 2024; -January 3, 2024; and -January 5-7, 2024. 3. A review of E4's personnel record revealed E4 was hired as a BHT. E4's personnel record revealed documentation of CPR training and first aid training (issued October 7, 2021 and expired October 2023). However, documentation of current CPR training and first aid training was not available for review. 4. In an interview, E1 reported E1 was unaware E4's CPR training and first aid training was expired. E1 reported E4 does not have current CPR training and first aid training. 5. In an interview, E1 acknowledged E4's personnel record was not maintained to include documentation of current CPR training and first aid training.

rule: B. An administrator shall ensure that: 4. Documentation is developed before an outing that includes: a. The name of each resident participating in the outing; b. A description of the outing; c. The date of the outing; d. The anticipated departure and return times; e. The name, address, and, if available, telephone number of the outing destination; and f. If applicable, the license plate number of each vehicle used to transport a resident;

evidence: Based on documentation review and interview, the administrator failed to ensure documentation was developed before an outing to include the name of each resident participating in the outing.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Outings" (date unavailable). The policy and procedure stated " ...B. Outing logs: must be completed prior to leaving the house with the destination, date and time, license plate number, who is going ... When you come back you must enter the time you returned on the log." 2. A review of facility documentation revealed a document titled "Outing Form" (dated November 18, 2023). The document stated "Dog Show (Back to the bully Rumble 3)" with an anticipated departure time of 10:40AM and anticipated return time of 3:30PM. However, the name of each resident participating in the outing was not available for review. 3. In an interview, E1 acknowledged documentation was not developed before an outing to include the name of each resident participating in the outing.

rule: An administrator shall ensure that a time-out: 1. Is provided to a resident who voluntarily decides to go in a time-out;

evidence: Based on documentation review and interview, the administrator failed to ensure a time-out was provided to a resident who voluntarily decided to go in a time-out.

findings: R9-10-101(235) "Time-out" means providing a patient a voluntary opportunity to regain self-control in a designated area from which the patient is not physically prevented from leaving. 1. A review of facility documentation revealed a document titled "Youth Incident Report" (dated October 17, 2023). The document stated "Staff send [sic] client to bed and explained to [R2] that this is not acceptable behaviors." 2. A review of facility documentation revealed a document titled "Youth Incident Report" (dated November 8, 2023). The document stated "Staff [E2] redirected client [R6] to go outside and take a 5 minute calm down." 3. A review of facility documentation revealed a document titled "Youth Incident Report" (dated December 7, 2023). The document stated "Staff redirected client [R1] to go sit in the recreation room and client [R5] to go sit in the tv room. ... Staff redirected client [R1] again to have a seat in the recreation room." 4. In an interview, E1 reported sending residents to a different area is a method of separating residents when they have arguments or fights. 5. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

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

evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as R1's treatment plan did not allow for R1 to be around non-shatter-proof mirrors.

findings: 1. The Compliance Officer observed a common bathroom in an upstairs hallway. The Compliance Officer observed a large mirror in the bathroom. However, there was no evidence to indicate the mirrors were shatter-proof. The Compliance Officer observed an acrylic sheet placed over each mirror with an adhesive strip. However, the acrylic sheet peeled back when the Compliance Officer pulled at the corners of the sheet. 2. The Compliance Officer observed am unlocked common bathroom next to the front door. The Compliance Officer observed an oval-shaped mirror in the bathroom. However, there was no evidence to indicate the mirrors were shatter-proof. 3. A review of R1's (admitted in 2023) medical record revealed a behavioral health assessment (dated in 2023). The behavioral health assessment stated " ... [R1] endorsed that [R1 sought treatment through behavioral health residential facility due to [R1's] ... SI/DTS/self-harming bxs. ... HX/previous suicide attempts, multiple SI attempts; attempted to run into traffic 2 x." 4. A review of R1's medical record revealed a current treatment plan (dated in 2023). The treatment plan stated "NO, Client is not safe around nonshatterproof glass as there is HX of SI/DTS/HI/, and high impulsivity." 5. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

rule: B. An administrator shall ensure that: 5. A resident bathroom provides privacy when in use and contains: a. A shatter-proof mirror, unless the resident's treatment plan allows for otherwise;

evidence: Based on observation, record review, and interview, the administrator failed to ensure a resident bathroom contained shatter-proof mirrors, unless the resident's treatment plan allowed for otherwise. The deficient practice posed a risk as R1's treatment plan did not allow for R1 to be around non-shatter-proof mirrors.

findings: 1. The Compliance Officer observed a master bedroom and a bathroom was observed in the master bedroom. The Compliance Officer observed a large mirror in the bathroom. However, there was no evidence to indicate the mirror was shatter-proof. The Compliance Officer observed an acrylic sheet placed over each mirror with an adhesive strip. However, the acrylic sheet peeled back when the Compliance Officer pulled at the corners of the sheet. The Compliance Officer observed the acrylic sheet did not cover the entire mirror. 2. A review of R1's (admitted in 2023) medical record revealed a behavioral health assessment (dated in 2023). The behavioral health assessment stated " ... [R1] endorsed that [R1 sought treatment through behavioral health residential facility due to [R1's] ... SI/DTS/self-harming bxs. ... HX/previous suicide attempts, multiple SI attempts; attempted to run into traffic 2 x." 3. A review of R1's medical record revealed a current treatment plan (dated in 2023). The treatment plan stated "NO, Client is not safe around nonshatterproof glass as there is HX of SI/DTS/HI/, and high impulsivity." 4. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.


state: AZ

facility_name: MATTIES CARE HOUSE LLC

summary: Complaint;Compliance (Annual) - 11/2/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00198346, AZ00198421, AZ00201621, AZ00202219 and AZ00202638 conducted on November 2, 2023:

inspection_type: Complaint;Compliance (Annual)

rule: C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows: 3. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and

evidence: Based on observation and interview, the administrator failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses.

findings: 1. The Compliance Officer observed a thawed, opened cylinder of beef, wrapped in a ziplock bag, thawing on the kitchen counter. The beef was warm to the touch. The beef cylinder's label stated "Keep refrigerated or frozen. Thaw in refrigerator or microwave." 2. In an interview, E2 reported the meat had been frozen and was placed on the kitchen counter that morning. E2 acknowledged the meat was now warm and remained on the kitchen counter. 3. In an interview, E1 acknowledged the meat on the kitchen counter had remained outside of the refrigerator all day and was not maintained at 41\'b0 F or below.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 14. Poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

evidence: Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were locked and inaccessible to residents. The deficient practice posed a physical health and risk to residents.

findings: 1. The Compliance Officer observed the following in an unlocked cabinet beneath the kitchen sink: -Dishwasher pods -Dishwasher detergent The containers contained warning labels. 2. The Compliance Officer observed nine residents on the premises. 3. In an interview, E1 acknowledged the poisonous or toxic materials stored by the facility were not locked away and inaccessible to residents. E1 reported to be unaware the two items were considered toxic and required being locked up.


summary: Complaint - 5/1/2023

raw_content: An on-site investigation of complaint AZ00194697 was conducted on May 1, 2023 and no deficiencies were cited.

inspection_type: Complaint


summary: Complaint - 4/27/2023

raw_content: An on-site investigation of complaint AZ00194441 was conducted on April 27, 2023 and no deficiencies were cited.


facility_name: ZAREPHATH CHAPARRAL HOUSE

summary: Compliance (Annual) - 10/20/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 20, 2025.

inspection_type: Compliance (Annual)


summary: Compliance (Annual) - 9/18/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on September 18, 2024.


summary: Compliance (Annual) - 9/13/2023

raw_content: The following deficiency was found during the on-site compliance inspection conducted on September 13, 2023:

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: g. Is a: ii. Shared bedroom that: (2) Except as provided in subsection (C), contains at least 60 square feet of floor space, not including a closet, for each individual occupying the shared bedroom; and

evidence: Based on observation and interview, the administrator failed to ensure a shared resident bedroom contained at least 60 square feet of floor space, not including a closet, for each individual occupying the shared bedroom.

findings: 1. The Compliance Officer observed two beds in a bedroom located on the second floor of the facility, directly across from the stairwell. Using an electronic measuring device, the Compliance Officer measured the bedroom to be 119 square feet. 2. In an interview, E6 acknowledged the bedroom did not contain at least 60 square feet of floor space for each individual occupying the bedroom.


facility_name: NEW HOPE OF ARIZONA, INC

summary: Complaint - 10/28/2025

raw_content: The following deficiency was found during the on-site  investigation of complaint 00148905 conducted on October 28, 2025:

rule: R9-10-716.D.2.a.i-v. Behavioral Health Services D. An administrator of a behavioral health residential facility authorized to provide behavioral health services to individuals under 18 years of age: 2. Shall ensure that: a. A resident does not receive the following from other residents at the behavioral health residential facility: i. Threats, ii. Ridicule, iii. Verbal harassment, iv. Punishment, or v. Abuse;

evidence: Based on record review and interview, the administrator failed to ensure that a resident did not receive ridicule, verbal harassment, punishment, or abuse from other residents at the behavioral health residential facility. The deficient practice posed a risk to residents as R4 was physically aggressive towards other residents.

findings: 1. A review of R4's medical record revealed a behavioral health assessment completed in August 2025. The assessment revealed R4 had a history of physical abuse. In addition, R1 had a history of being physically aggressive and a history of self-harm. 2. A review of R4's medical record revealed an incident report dated September 29, 2025. The incident report stated, “Staff directed the member to sit in the back of the vehicle. The member declined and responded with verbal aggression and cursing shortly after, another member placed a hand near the member's face, at which point [R4] slapped the member, resulting in a bloody nose.” 3.In an interview, E1 acknowledged the personal history of R4. E1 acknowledged the incident on September 29, 2025, resulting in R4 becoming physically aggressive with another resident, resulting in an injury. E1 acknowledged that the administrator failed to ensure that a resident did not receive ridicule, verbal harassment, punishment, or abuse from other residents at the behavioral health residential facility.


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

raw_content: No deficiencies were found during the on-site compliance inspection conducted on August 8, 2025.


summary: Compliance (Annual) - 8/5/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on August 5, 2024.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 2. A food menu: c. Is conspicuously posted at least one calendar day before the first meal on the food menu will be served,

evidence: Based on observation and interview, the registered dietitian failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu will be served. The deficient practice posed a risk if the dietary guidelines per R9-10-719(B)(4), were not followed.

findings: 1. The Compliance Officer observed a food menu posted at the facility. However, the menu identified a date of "July 28, 2024, through August 3, 2024." 2. In an interview, E1 acknowledged a food menu was not conspicuously posted at least one calendar day before the first meal on the food menu would be served.


summary: Complaint;Compliance (Annual) - 7/26/2023

raw_content: The following deficiencies were found during the compliance inspection and investigation of complaint AZ00187857 conducted on July 26, 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.

findings: 1. A review of the facility policies and procedures reviewed July 1, 2020, 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, R2, and R3'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.

rule: C. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that food is obtained, prepared, served, and stored as follows: 4. A refrigerator contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;

evidence: Based on observation and interview, the administrator failed to ensure a refrigerator contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator.

findings: 1. The Compliance Officers observed a refrigerator in the kitchen contained food items. However, the refrigerator did not contain a thermometer. 2. In an interview, E1 reported the refrigerator was new and the thermometer was not transferred from the old fridge to the new fridge. E1 acknowledged the refrigerator did not contain a thermometer, accurate to plus or minus 3\'b0 F.

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, documentation review and interview, the administrator failed to ensure equipment used at the behavioral health residential facility was maintained in working order. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. The Compliance Officer observed wires hanging from the ceiling where a smoke detector may have been removed, in a resident bedroom. 2. In an interview, E1 reported E1 was notified the smoke detector was removed in order to replace the batteries. At the time of the inspection, the smoke detector was not located at the facility. E1 acknowledged equipment used at the behavioral health residential facility was not maintained in working order.

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,

evidence: Based on observation and interview, the administrator failed to ensure at least one bathroom was accessible from the common area and contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control.

findings: 1. The compliance officer observed one bathroom accessible from the common area. However, the bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. 2. In an interview, E1 acknowledged the administrator failed to ensure a bathroom accessible from the common area contained paper towels in a dispenser or a mechanical air hand dryer.


facility_name: LIFE CHANGE FAMILY SERVICES INC

summary: Complaint - 3/23/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00162262 conducted on March 23, 2026.


summary: Complaint;Compliance (Annual) - 2/27/2026

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00160213 conducted on February 27, 2026:

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, record review, and interview, the administrator failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training in fall prevention and fall recovery, for two of five personnel records sampled. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of documentation revealed a policy and procedure, revised July 15, 2024, titled "Fall prevention." The document stated, "All staff are required to review fall prevention techniques every 12- (sic) months and proof of this training be updated in their personnel files." 2. A review of documentation revealed a document which stated, "...7/15/24 - [O1] and [E5] reviewed policy and added slip and fall to yearly staff orientation and training." 3. A review of documentation revealed a policy and procedure titled, "Orientation and Training." The document stated, "...New Staff orientation shall include a review of:...slip/fall prevention. Throughout the year all staff will be required to complete 24-hours of ongoing training and be recertified yearly (12 months), which includes:...Slip/fall prevention." 4. A review of E4's (hired in 2018) and E5's (hired in 2019) personnel records revealed no documentation of continued competency training in fall prevention and fall recovery. 5. In an interview, E3 acknowledged E4 and E5 had not completed the continued competency training. E3 reported E4 and E5 would complete the training as soon as possible. 6. In an exit interview, the findings were reviewed with E3, and no additional comments or documentation were provided. This is a repeated violation from the February 2, 2024 compliance inspection; and the February 14, 2023 compliance and complaint inspection.

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 record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (F), for five of five personnel records sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113.A.2.c. 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: Include: 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; 1. A review of E1’s (hired in 2026) personnel record revealed E1 was hired as a behavioral health technician (BHT). However, the personnel record revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. 2. A review of E2’s (hired in 2025) personnel record revealed E2 was hired as a BHT. However, the personnel record revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. 3. A review of E3’s (hired in 2025) personnel record revealed E3 was hired as the assistant administrator. However, the personnel record revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. 4. A review of E4’s (hired in 2018) personnel record revealed E4 was hired as a registered nurse. However, the personnel record revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. 5. A review of E5’s (hired in 2025) personnel record revealed E5 was hired as a behavioral health professional (BHP). However, the personnel record revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. 6. In an interview, E3 reported to be unaware of this requirement and acknowledged E1, E2, E3, E4, and E5 had not completed the annual training and education. E3 reported E1, E2, E3, E4, and E5 would complete this training as soon as possible. 7. In the exit interview, the findings were reviewed with E3, and no additional comments or documentation were provided.

rule: R9-10-712.C.18. Medical Records C. An administrator shall ensure that a resident's medical record contains: 18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13), for two of two medical records sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113.A.2.a.i.ii.iii states, 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: 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) 1. A review of R1's medical record revealed no documentation of freedom from infectious tuberculosis (TB) or an assessment of risks of prior exposure to TB. 2. A review of R2's medical record revealed no documentation of an assessment of risks of prior exposure to TB. 3. In an interview, E3 reported R1 had refused to have a TB skin test completed, and acknowledged neither R1 or R2 had documentation of an assessment of risks of prior exposure to TB. 4. In an exit interview, the findings were reviewed with E3, and no additional comments or documentation were provided.

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

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

findings: 1. A review of documentation revealed a document titled, "Emergency Disaster," dated, "November 2025." The document did not include a day or time. The document stated, "Review of Plan," and was signed by E2, E3 and four other personnel members. The document stated, "...Note: The disaster plan is to be reviewed by all staff on each shift at least once every 4 months, and food and other supplies need to be checked and updated quarterly." 2. A review of documentation revealed a document titled, "Emergency Disaster," dated, "July 2025." The document did not include a day or time. The document stated, "Review of Plan," and was signed by E2, E3 and four other personnel members. The document stated, "...Note: The disaster plan is to be reviewed by all staff on each shift at least once every 4 months, and food and other supplies need to be checked and updated quarterly." 3. A review of documentation revealed a document titled, "Emergency Disaster Review Plan," dated April 28, 2025 at 1:00 PM. The document stated, "Review of Plan," and was signed by E1, E3 and four other personnel members. The document stated, "...Note: Disaster plan is to be reviewed by all staff on each shift at least once every quarter." 4. A review of documentation revealed a document titled, "Emergency Disaster," dated March 10, 2025. The document did not include a time. The document stated, "Review of Plan," and was signed by six personnel members. The document stated, "...Note: The disaster plan is to be reviewed by all staff on each shift at least once every 4 months, and food and other supplies need to be checked and updated quarterly." 5. In an interview, E3 reported the facility had one weekend shift and the following weekday shifts: 9:00 AM - 5:00 PM, 9:00 AM - 1:00 PM, 1:00 PM - 9:00 PM, 12:00 PM - 9:00 PM, and 9:00 PM - 9:00 AM. 6. In an interview, E3 acknowledged the facility's disaster drills were not documented as being completed once every three months on each shift. 7. In the exit interview, the findings were reviewed with E3, and no additional comments or documentation were provided. This is a repeated violation from the February 2, 2024 compliance inspection.

rule: R9-10-721.A.1.c. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

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

findings: 1. The Compliance Officer observed a bedroom occupied by R1. The Compliance Officer observed one center metal closet bracket (of a triangular shape) with a hook, supporting a plastic clothing rod in the closet. The plastic clothing rod did not not give way when the Compliance Officer applied downward pressure due to the center support, the center support hook on the metal bracket did not give way when the Compliance Officer applied downward pressure, and the bottom of the metal closet bracket posed a ligature risk. 2. The Compliance Officer observed a bedroom occupied by R2. The Compliance Officer observed one center metal closet bracket (of a triangular shape) with a hook, supporting a plastic clothing rod in the closet. The plastic clothing rod did not not give way when the Compliance Officer applied downward pressure due to the center support, the center support hook on the metal bracket did not give way when the Compliance Officer applied downward pressure, and the bottom of the metal closet bracket posed a ligature risk. 3. The Compliance Officer observed a third resident bedroom. The Compliance Officer observed one center metal closet bracket (of a triangular shape) with a hook, supporting a plastic clothing rod in the closet. The plastic clothing rod did not not give way when the Compliance Officer applied downward pressure due to the center support, the center support hook on the metal bracket did not give way when the Compliance Officer applied downward pressure, and the bottom of the metal closet bracket posed a ligature risk. 4. A review of R2's medical record revealed a behavioral health assessment (dated in 2025). The assessment stated " ...2. Has youth ever thought about harming self? Yes; 3. Has youth ever harmed self? Yes..." 5. In an interview, E3 acknowledged the center metal closet bracket with a hook could be a potential safety risk for a resident and reported the facility would have them removed. 6. In the exit interview, the findings were reviewed with E3, and no additional comments or documentation were provided.


summary: Complaint - 1/16/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00156321 conducted on January 16, 2026.


summary: Complaint - 12/5/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00152359 conducted on December 5, 2025.


summary: Complaint - 8/12/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00139128 conducted on August 12, 2025:

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 sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge to ensure the health and safety of a resident, for one of two sampled residents. The uncorrected violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report (dated August 2025) regarding R1. The incident report stated, “[R1] attempted to AWOL’d [sic] from group home after being suspended from school for three days because [R1] hit a teacher yesterday 8/7/25. [R1] was told to straighten up the back patio area and instead [R1] fled…Admin [E2] called 911 to report the incident…Police called and said they found [R1]. They returned [R1] back home safely. One on one coaching was done and [R1] was sent to start school work on [R1’s] computer from school…” R1 was identified as absent without authorization at 10:10 a.m. 2. A review of facility documentation revealed a daily staff schedule (dated August 2025). The schedule indicated E2 (hired April 2025) was scheduled to work from 9:00 a.m.-1:00 p.m. the day of the incident. 3. A review of facility documentation revealed a daily staff schedule (dated June 2025). The schedule indicated E2 (hired April 2025) was scheduled to work from 9:00 a.m.-1:00 p.m. the day of the incident. 4. A review of E2's (hired in April 2025) personnel record indicated E2's job title was "Assistant Administrator." E2's record revealed an employment application (dated April 2025). The application indicated E2's previous employment was as a "Senior Quality Control Manager" at a large bank. The application stated E2's job responsibilities were: "Listening to phone calls and grade them on accuracy." 6. A review of the facility documentation revealed an undated job description for an Assistant Administrator. However, the job description did not include the qualifications, experience, skills, and knowledge necessary for the job. 7. In an exit interview, the findings were discussed with E2, and no additional documentation or statements were provided. This Rule was cited on October 1, 2024. A letter to the licensee, dated October 11, 2024, stated, "The Department requires that you make immediate correction(s) of violation(s) that present a threat to the health or safety of consumers."

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 record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member that included documentation of the individual's compliance with requirements in A.R.S. §§ 36-411, for one of four sampled personnel members. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the behavioral health residential facility, and the uncorrected violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of E2’s personnel record revealed an expired Department of Public Safety (DPS) fingerprint clearance card. The card expired in February 2024. The record revealed a DPS application dated in April 2025. 2. A review of the DPS website revealed no application for E2 had been submitted. 3. In an interview, E2 reported having submitted the fingerprint clearance card application in April 2025. E2 indicated E2 had not yet received the card in the mail.  4. In an exit interview, the findings were discussed with E2, and no additional documentation or statements were provided. This Rule was cited on April 11, 2025. A letter sent to the licensee, dated April 18, 2025, stated, "The Department requires that you make immediate correction(s) of violation(s) that present a threat to the health or safety of consumers."

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 documentation review, record 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, for one of two residents sampled. The deficient practice posed a risk as R1 was not discharged from the facility after exhibiting behaviors that were dangerous to self and others, and R1 was not benefiting from the treatment provided at the behavioral health residential facility.

findings: 1. A review of facility documentation revealed an incident report (dated August 2025) regarding R1. The incident report stated, “[R1] attempted to AWOL’d [sic] from group home after being suspended from school for three days because [R1] hit a teacher yesterday 8/7/25. [R1] was told to straighten up the back patio area and instead [R1] fled…Admin [E2] called 911 to report the incident…Police called and said they found [R1]. They returned [R1] back home safely. One on one coaching was done and [R1] was sent to start school work on [R1’s] computer from school…” The incident occurred at 10:10 a.m. 2. A review of facility documentation revealed an incident report (dated June 2025) regarding R1. The incident report stated, "[R1] was asked to participate in group and refused. [R1] decided to have a meltdown and disrupt the group screaming and crying so staff redirected [R1] to the mancave with [E1] to sit while [E5] did the other [residents'] group. [R1] began to choke [R1] with [R1's] sweater. Staff took the sweater off [R1's] neck and [R1] began to hit [R1] in the nose until [R1] started to bleed...Staff stopped [E5] stopped [R1] and administer [sic] first aid...[R1] was removed from group and remained in line of sight until bedtime." 3. A review of R1's record revealed a document (dated May 2025), titled "Intake Assessment." The document stated R1's diagnoses were "ADHD [Attention Deficit with Hyperactivity Disorder], ODO [Oppositional Defiant Disorder], Epilepsy, Autism." 4. In a telephone interview, E4 stated R1 was not discharged because R1 was engaging in behaviors that were dangerous to self and others "for attention." 5. A review of the facility's documentation revealed a policy and procedure (dated July 15, 2024), titled "R9-10-703 Administration" Scope of Services." The policy stated, "[Life Change Family Services] serves the population of males between the ages of 7-17. Individuals who have histories of substance abuse, conduct disorder, poor anger management, domestic violence offenders, maladaptive sexual behaviors and those who have been court ordered into treatment." 6. In an interview, E2 reported R1 was not benefitting from treatment because the facility staff did not see any changes in R1's behavior. 7. In an exit interview, the findings were discussed with E2, and no additional documentation or statements were provided.


summary: Complaint - 4/11/2025

raw_content: The following deficiency was found during the on-site investigation of complaint 00126125 conducted on April 11, 2025:

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) § 36-411(A) and A.R.S. § 36-425.03(E), for one of one personnel member sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population.

findings: A.R.S. § 36-411(A) states "Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institution, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." A.R.S. § 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. A review of Department documentation revealed BH5008 was licensed as a children's behavioral health residential facility, effective September 15, 2016. 2. A review of E2's fingerprint clearance card, provided by E2, revealed E2's fingerprint clearance card was issued on February 8, 2018 with an expiration date of February 8, 2024. However, a current fingerprint clearance card was not provided for review. 3. A review of the Arizona Department of Public Safety (AZDPS) fingerprint clearance card status website (https://psp.azdps.gov/services/cardStatusRequest) revealed "Current status: Expired" for E2's fingerprint clearance card. 4. In an interview, E2 reported E2 had the documentation to apply for a new fingerprint clearance card; however, the documentation had not been submitted to AZDPS. 5. A review of E2's personnel record revealed documentation of compliance with A.R.S. § 36-411(A) and A.R.S. § 36-425.03(E) was not available for review. 6. In an interview, E2 reported the documentation was in another folder from when E2 previously worked at BH5008. However, documentation of compliance with A.R.S. § 36-425.03(E) was not provided for review. 7. In a joint interview, E1 and E2 reported E2 would come into compliance with A.R.S. § 36-425.03(E). 8. In a joint interview, E1 and E2 reported E1 and E2 were in the process of completing a new personnel record for E2 as E2 was a rehire and began working at BH5008 again in the first week of April. 9. In a joint exit interview, E1 and E2 acknowledged E2's personnel record was not maintained to include documentation of the requirements in A.R.S. § 36-411(A) and A.R.S. § 36-425.03(E).


summary: Compliance (Annual) - 3/4/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on March 4, 2025.


summary: Complaint - 10/1/2024

raw_content: An on-site investigation of complaint AZ00216662 was conducted on October 1, 2024 and the following deficiencies were cited :

rule: C. An administrator shall ensure that: 3. Policies and procedures are reviewed at least once every three years and updated as needed;

evidence: Based on documentation review and interview, the administrator failed to ensure the policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a health and safety risk to residents as policies and procedures provide guidance to employees on how to perform their tasks.

findings: 1. A review of facility documentation revealed a policy manual for Life Change Family Services. A page titled "Policy and Procedure Annual Review" stated "policies and procedures were reviewed and updated on December 20, 2016 by: Program Director Claudette Walker-Simon BHT. Policies and procedures will be updated every 24-months by the program director and the clinical supervisor and a copy of the review shall be placed in the policy and procedure manual." A further review indicated the policy and procedure manual had not been reviewed or updated since 2016. 2. In an interview, E3 acknowledged the policy and procedure manual had not been reviewed and updated a least every three years as required in R9-10-703.C.3 or per the facility policy and procedures.

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.

evidence: Based on 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 ensure the health and safety of a resident. The deficient practice posed a risk the the health and safety of the residents due to the severity of the violation.

findings: 1. A review of the facility's documentation, revealed a document titled "Arizona Department of Child Safety Significant Incident" written in September 2024 at 5:00 PM. The incident report stated "[R1] was outside getting water from the outside water cooler when another resident poured hot water on [R1's] left foot. The outside water dispenser, dispenses hot and cold water and [R2] intentionally poured hot water on [R1's] foot." "The burn is described as a "second degree burn" 2. In an interview, R1 was asked if R1 was afforded medical care. R1 stated "no". The Compliance Officer observed R1's foot to be red around the affected area and appeared to be infected. 3. In an interview, E2 was asked if R1 was afforded medical care. E2 stated E2 provided first aid care to R1 the day the incident took place. E2 stated R1's burn did not "look bad" when it first happened. However, the next day, E2 described the burn as looking "really bad". E2 confirmed R1 was sent to school anyway. 4. In an interview, E3 was asked if R1 was afforded medical care for R1's foot burn. E3 stated "yes." However, according to E3, medical care was provided to R1 the next day, at school by the school nurse and the paramedics who were called to assess R1. E3 informed R1 was treated and the recommendations did not include taking R1 to the hospital. However, based on the Compliance Officer's observation of R1's burn on October 1, 2024, E3 was advised to provide follow-up treatment for R1 as soon as possible. 5. In an interview, E3 acknowledged, based on the documentation provided, sufficient personnel members with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident were not present on the facility premises.

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

evidence: Based on documentation review and interview, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a R1 was not provided immediate medical attention.

findings: 1. A review of the facility's documentation, revealed a document titled "Arizona Department of Child Safety Significant Incident" written in September 2024 at 5:00 PM. The incident report stated "[R1] was outside getting water from the outside water cooler when another resident poured hot water on [R1's] left foot. The outside water dispenser, dispenses hot and cold water and [R2] intentionally poured hot water on [R1's] foot." "The burn is described as a "second degree burn" 2. In an interview, R1 was asked if R1 was afforded medical care. R1 stated "no". The Compliance Officer observed R1's foot to be red around the affected area and appeared to be infected. 3. In an interview, E2 was asked if R1 was afforded medical care. E2 stated E2 provided first aid care to R1 the day the incident took place. E2 stated R1's burn did not "look bad" when it first happened. However, the next day, E2 described the burn as looking "really bad". E2 confirmed R1 was sent to school anyway. 4. In an interview, E3 was asked if R1 was afforded medical care for R1's foot burn. E3 stated "yes." However, according to E3, medical care was provided to R1 the next day, at school by the school nurse and the paramedics who were called to assess R1. E3 informed R1 was treated and the recommendations did not include taking R1 to the hospital. However, based on the Compliance Officer's observation of R1's burn on October 1, 2024, E3 was advised to provide follow-up treatment for R1 as soon as possible. 5. In an interview, E2 and E3 corroborated the incident report allegations. E3 acknowledged professional medical care was not provided to R1 until R1 complained of R1's foot hurting at school.

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 health and safety of an individual under the age of 18, was potentially abused or neglected while personnel should have been providing continuous protective oversight. Finding include: 1. A review of the facility's documentation, revealed a document titled "Arizona Department of Child Safety Significant Incident" written in September 2024 at 5:00 PM. The incident report stated "[R1] was outside getting water from the outside water cooler when another resident poured hot water on [R1's] left foot. The outside water dispenser, dispenses hot and cold water and [R2] intentionally poured hot water on [R1's] foot." "The burn is described as a "second degree burn" 2. A review of R1's medical record revealed an intake assessment dated in September 2024, which stated, "diagnosis'... ADHD, ODD, depression, anxiety, dyslexic and dysgraphia possible autism." Under "reason for admission" stated "[R1] is physically aggressive, has sexualized behaviors, and has a history of breaking things and admits having auditory and visual hallucinations." 3. A review of R2's medical record revealed an intake assessment dated in August 2024, which stated, "diagnosis'... "cerebral palsy, ADHS, currently awaiting psychological evaluation." Additionally, "per adoptive mother [R2] makes threats of harm to injure or cause harm to others. Caused injury to another child by hitting, kicking, and dragging." 4. In an interview E3 acknowledged R1's and R2's diagnosis' and need for continuous protective oversight as individuals under the age of 18.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 10. Hot water temperatures are maintained between 95° F and 120° F in the areas of the behavioral health residential facility used by residents;

evidence: Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of the behavioral health residential facility used by residents. The deficient practice posed a health and safety risk to residents as the hot water temperatures were a burn risk to residents, and a negative outcome occurred due to the violation.

findings: 1. During the environmental inspection of the facility, the Compliance Officer observed the hot water temperature in an electric water dispenser for hot and cold water located on the back porch of the facility, measured 182\'b0 F. 2. In an interview, E3 acknowledged the temperature of the hot water in the facility was not maintained between 95\'b0 F and 120\'b0 F.


summary: Complaint - 9/13/2024

raw_content: An on-site investigation of complaint AZ00215895 was conducted on September 13, 2024 and the following deficiencies were cited :

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: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident: a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or b. For a resident under 18 years of age, according to A.R.S. § 13-3620; 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); 4. Maintain the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident ' s physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

evidence: Based on documentation review and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620, to believe abuse, neglect, or exploitation occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator reported, documented, and initiated an investigation of the suspected abuse. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection as documentation did not exist, according to E1.

findings: 1. In an interview, E1 reported being informed by the Arizona Department of Child Services on September 7, 2024, R1 would not return to the group home after R1's visit was completed with R1's parents, as a result of "abuse allegations" made by R1 against BH5008. 2. In an interview, E1 was asked to provide the incident report regarding the "abuse allegations" R1 had made to DCS and the facility documentation of the investigation the facility would be required to conduct. E1 reported an incident report or an investigation had not been completed as per R9-10-703.I.1-6. 3. In an interview, E1 acknowledged the facility did not follow requirements according to R9-10-703.I.1-6.

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: 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 requirements in A.R.S. \'a7 8-804, for one of three personnel members sampled.

findings: A.R.S. \'a7 8-804(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." A.R.S. \'a7 8-804(K) "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 E3's personnel record revealed E3 was hired as a behavioral health technician in 2022. E3's personnel record 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 E3. The review further revealed no documentation demonstrating E3 certified whether an allegation of abuse or neglect was made against E3 and was substantiated. 2. In an interview, E1 acknowledged E3 was not in compliance per A.R.S. \'a7 8-804.

evidence: Based on documentaion review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration, for one resident sampled. The deficient practice posed a risk to the safety of R1 if allegations of abuse were reported to staff and staff failed to ensure safety. Therefore, failing to uphold resident rights.

findings: 1. In an interview, E1 reported being informed by the Arizona Department of Child Services on September 7, 2024, R1 would not return to the group home after R1's visit was completed with R1's parents, as a result of "abuse allegations" made by R1 against BH5008. 2. In an interview, E1 was asked to provide the incident report regarding the "abuse allegations" R1 had made to DCS and the facility documentation of the investigation the facility would be required to conduct. E1 reported an incident report or an investigation had not been completed as per R9-10-703.I.1-6. 3. In an interview, E1 acknowledged the facility did not follow policies and procedures according to R9-10-703.I.1-6 and R1 was not treated with dignity, respect, and consideration.


summary: Compliance (Annual) - 2/2/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on February 2, 2024:

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.

evidence: Based on observation, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the health and safety of residents if personnel were not trained in fall prevention and fall recovery in the event a resident suffered a fall.

findings: 1. The Compliance Officer requested to review the facilities fall prevention and fall recovery training program, which included initial training and continued competency for all personnel. However, the program was not provided for review. 2. The Compliance Officer observed E1 had updated the facility's policies and procedures to include fall prevention and fall recovery training program, which included initial training and continued competency for all personnel during the inspection on February 2, 2024. 3. A review of E2's, E3's, E4's, and E6's personnel records revealed initial training in fall prevention and fall recovery was not available for review. 4. In an interview, E1 acknowledged documented training in fall prevention and fall recovery for E2, E3, E4, and E6 was not available for review. E1 acknowledged the facility did not develop and administer a training program regarding fall prevention and fall recovery, which included initial training and continued competency for all personnel prior to February 2, 2024. This is a repeat deficiency from the compliance inspection conducted on February 14, 2023.

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 two of two residents sampled. The deficient practice posed a risk as the information was required for the development and implementation of a treatment plan, as per R9-10-708.A.

findings: 1. A review of R1's medical record (admitted November 2023) revealed a nursing assessment. However, based on R1's date of admission, the nursing assessment was not dated within 30 calendar days before admission or within 72 hours after admission. 2. A review of R2's medical record (admitted November 2023) revealed a nursing assessment. However, based on R2's date of admission, the nursing assessment was not dated within 30 calendar days before admission or within 72 hours after admission. 3. In an interview, E1 acknowledged R1's and R2's nursing assessments were not dated within 30 calendar days before admission or within 72 hours after admission.

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 and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.

findings: 1. The Compliance Officer requested to review disaster drills. However, documentation disaster drills had been conducted or documented for the past 12 months was not provided for review. 2. In an interview, E1 attempted to locate the disaster drill documentation, however, documentation was not provided. E1 acknowledged disaster drills for employees had not been conducted on each shift at least once every three months and documented.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. A pest control program that complies with A.A.C. R3-8-20l(C)(4) is implemented and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a pest control program complied with A.A.C. R3-8-20l(C)(4) was implemented and documented. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of the facility documentation revealed no evidence of a pest control program implemented and documented. 2. In an interview, E1 acknowledged the facility did not have a pest control program implemented and documented, which complied with A.A.C. R3-8-20l(C)(4).


summary: Complaint - 8/2/2023

raw_content: An on-site investigation of complaint AZ00198657 and AZ00198591 was conducted on August 2, 2023 and the following deficiencies were cited :

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure documentation of current contracted services was maintained, for one of four personnel members sampled.

findings: 1. A review E5's personnel record, revealed a contract between the facility an an individual registered nurse, was not available for review. 2. In an interview, E1 reported E5 was hired in 2016, and a contract has never existed.

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 that a treatment plan included 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.

findings: 1. A review of R1's medical record, revealed a treatment plan titled, "Life Change Family Services Individual Service Plan" dated June 06, 2023. The service plan revealed no documentation of the signature of the resident and/or the resident's representative, and/or documentation of the refusal to sign. 2. In an interview E1 acknowledged R1's treatment plan did not include the signature of the resident and/or the resident's representative, and/or documentation of the refusal to sign.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: d. The date when the resident's treatment plan will be reviewed;

evidence: Based on record review and interview, the administrator failed to ensure that a treatment plan includes the date when the resident's treatment plan would be reviewed for one of one resident sampled.

findings: 1. A review of R1's medical record, revealed a treatment plan dated June 6, 2023. The treatment plan revealed no documented evidence of the date when the resident's treatment plan would be reviewed. 2. In an interview, E1 acknowledged R1's treatment plan, revealed no documented evidence of the date when the resident's treatment plan would be reviewed.

rule: B. An administrator shall ensure that: 1. A request for participation in developing a resident's treatment plan is made to the resident or the resident's representative, 2. An opportunity for participation in developing the resident's treatment plan is provided to the resident or the resident's representative, and 3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident's medical record.

evidence: Based on record review, and interview, the administrator failed to ensure that a request for participation in developing a resident's treatment plan is made to the resident or the resident's representative; an opportunity for participation in developing the resident's treatment plan is provided to the resident or the resident's representative, and the request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident's medical record for one of one resident sampled.

findings: 1. A review of R1's medical record, did not reveal evidence a request for participation in developing R1's treatment plan was made to R1 or the R1's representative; an opportunity for participation in developing R1's treatment plan was provided to R1 or R1's representative, and the request in subsection (B)(1) and the opportunity in subsection (B)(2) were documented in R1's medical record. 2. In an interview, E1 acknowledged R1's medical record did not reveal evidence a request for participation in developing a resident's treatment plan was made to the resident or the resident's representative; an opportunity for participation in developing the resident's treatment plan was provided to the resident or the resident' s representative; and the request in subsection (B)(1) and the opportunity in subsection (B)(2) were documented in the resident's medical record.

rule: B. An administrator shall ensure that: 1. A request for participation in developing a resident's discharge plan is made to the resident or the resident's representative, 2. An opportunity for participation in developing the resident's discharge plan is provided to the resident or the resident's representative, and 3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident's medical record.

evidence: Based on record review and interview, the administrator failed to ensure that a request for participation in developing the resident's discharge plan is provided to the resident or the resident's representative, an opportunity for participation in developing the resident's discharge plan is provided to the resident or the resident's representative and is documented in the resident's medical record for one of one resident sampled.

findings: 1. A review of R1's medical record did not reveal documentation an opportunity for participation in developing the resident's discharge plan was provided to the resident or the resident's representative; the request in subsection (B)(1) and the opportunity in subsection (B)(2) were documented in the resident's medical record. 2. In an interview, E1 acknowledged R1's medical record did not reveal documented evidence, pursuant R9-10-709.B.1-3.


facility_name: MISS A'S LLC

summary: Complaint - 2/18/2026

raw_content: The following deficiency was found during the investigation of complaint 00159059 conducted on February 18, 2026:

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, record review, and interview, the administrator failed to ensure continuous protective oversight was provided to a resident admitted to the behavioral health residential facility with limited ability to function independently, for two of two resident records sampled. The deficient practice posed a direct health and safety risk when R1 and R2 were no longer provided continuous protective oversight and were not under the supervision of another responsible party such as a school, case manager, probation officer, or guardian; and the deficient practice posed a risk as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: A.R.S. § 36-401.A. 13. "Continuous" means available at all times without cessation, break or interruption. 1. A review of Department documentation revealed the facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a policy titled "Unauthorized Absence/AWOL (Absence without leave)," dated September 24, 2025. The policy stated, "... Miss A's will consider member AWOL if/when the member has left the home without permission..." 3. A review of facility documentation revealed a "Member AWOL log." The log revealed the following information: Member: [R2]; Date Reported: 02/10/2026; Time Reported: 2:30 PM; Reported to Whom: [E1] Administrator, Glendale PD, [O1] Guardian, [O2] Case High Needs Case Manager, [E6] Therapist; and Member: [R1]; Date Reported: 02/06/2025; Time Reported: 9:30 PM; Reported to Whom: [E1] Administrator, Glendale PD, [O3] Guardian, [O4] High Needs Case Manager, and [E6] Therapist. 4. A review of facility documentation revealed a daily staffing schedule dated February 2026. The schedule revealed E4 was scheduled to work alone on Friday, February 6, 2026, from 3:00 PM to 10:00 PM, and E3 and E5 were scheduled to work on Tuesday, February 10, 2026, from 8:00 AM to 4:00 PM. 5. A review of R1’s medical record revealed a document titled "ABC Checklist" (dated after R1's unauthorized absence in February 2026). The checklist stated "Member: [R1] ... Behaviors: … X Running away … Duration: … 3+ hours.” 6. A review of R1’s medical record revealed a document titled "Incident Report" (dated in February 2026). The report stated " ... At approximately 9:30 PM, [R1] was observed engaging in a verbal argument with a peer while entering [R1’s] bedroom to prepare for bed. [R1] was redirected by staff and complied; however, [R1] was later observed pacing in [R1’s] bedroom. Staff offered the member the option to sleep on the couch if [R1] did not feel comfortable sleeping the bedroom with the peer. [R1] declined. At approximately 10:20 PM, during a welfare check, staff observed pillows placed under [R1’s] blankets, creating the appearance that [R1] was asleep in [R1’s] bed. Staff searched [R1’s] closet and room and determined [R1] was not present and had gone AWOL from the BHRF. On-call management and the Glendale Police Department were notified immediately. … [R1] returned to the BHRF on [R1’s] own at approximately 8:00 AM. … The UA results were negative for all substances. [R1] was compliance with processing and reported that [R1] had walked around throughout the night.” 7. A review of R1’s medical record revealed a document titled "Safety Crisis Plan" (dated after R1's unauthorized absence in February 2026). The document stated " ... At approximately 9:30PM… [R1] was observed to engage in a verbal argument with a peer as [R1] was going into [R1’s] bedroom for bed. [R1] was redirected and [R1] complied; however, [R1] was pacing in [R1’]s bedroom until [R1] asked for melatonin to help [R1] sleep. Staff informed [R1] that [staff] would retrieve the melatonin and administer it once [staff] completed [staff’s] start of shift checklist and asked [R1] to give [staff] 20 minutes. [R1] verbally stated [R1] understood and would wait. [R1] was not receptive to processing at this point and just stated [R1] wanted to go to sleep and forget about the argument. When staff retuned to [R1’s] bedroom at approximately 10:20PM, staff observed [R1] had placed pillows under [R1’s] blankets, giving the impression [R1] was asleep in [R1’s] bed. Staff searched [R1’s] closet; however, [R1] was not present and had presumable gone AWOL from facility.” 8. In an interview, E1 reported R1 did not verbalize wanting to fight with a peer until R1 returned and explained R1’s purpose for the unauthorized absence. E1 reported E1 did not know where R1 went, and R1 had reported R1 walked around all night. 9. A review of R2’s medical record revealed a document titled "ABC Checklist" (dated after R2's unauthorized absence in February 2026). The checklist stated "Member: [R2] ... Behaviors: … X Running away … Duration: … 1-2 hours.” 10. A review of R2’s medical record revealed a document titled "Incident Report" (dated in February 2026). The report stated " ... [R2] asked to take a nap which was permitted. Staff checked on the member 15 minutes after [R2] requesting to nap in [R2’s] bedroom and [R2] was presumably AWOL. This was at approximately 2:50pm. There was no precursor to [R2] leaving. Staff and supporting staff did a check of the BHRF and perimeter. [R2] was not located. Staff called Glendale police to report [R2] AWOL while assisting staff drove the area to see if [R2] could be located. … Multiple officers searched the area… however, [R2] ran. The officer did not continue pursuit due to potential risk to [R2] and community traffic. [R2] returned at approximately 7:00pm.” 11. A review of R2’s medical record revealed a document titled "Safety Crisis Plan" (dated after R2's unauthorized absence in February 2026). The document stated " ... [R2] and peer were in a verbal altercation the night prior. … upon return stated [R2] was upset from the verbal altercation [R2] had with a peer. Staff and [R2] reviewed this altercation and how it could have been handled differently as well as communicating opposed to having flight response going AWOL.” 12. In an interview, E1 reported R2 was not pursued by E3 and E5 due to traffic concerns. E1 reported R2 returned to the facility on R2’s own. 13. In an interview, E1 reported residents are offered therapeutic interventions and offered opportunities to process. E1 reported personnel members do not follow residents when they leave the premises to prevent residents from running into the street. 14. In an exit interview, E1 reported the local fire Department prevents the doors from being locked, as it creates a hazard within the facility. E1 lastly reported that everything can be done correctly on behalf of the facility, but the facility would still be subject to being out of compliance. 15. 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 repeat violation from the on-site compliance inspection conducted on May 1, 2025, and from the on-site compliance and complaint inspection conducted on January 27, 2026.


summary: Complaint;Compliance (Annual) - 1/27/2026

raw_content:
This new Statement of Deficiencies supersedes the Statement of Deficiencies sent to the licensee on February 12, 2026.

The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00157110 conducted on January 27, 2026:

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 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 Department documentation revealed the facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently (individuals under 18 years of age). 2. A review of facility documentation revealed a document titled, "Member AWOL Log." The document reported R1 had the following unauthorized absences from the facility: October 30, 2025 at 10:45 PM; October 31, 2025 at 6:05 PM; and December 3, 2025 at 6:10 PM. 3. A review of the facility documentation revealed a document titled, "Incident Report Form," dated October 30, 2025. The document stated, "...On the night of Thursday, October 30, 2025, at approximately 10:45pm, staff conducted their welfare safety checks and upon entering [R1's] bedroom, [R1] was found to have an empty bed. [R1] is assumed to have AWOL'd, as they were not present in their bedroom, or any location within the BHRF. Cameras in the home were reviewed and [R1] and [R1's] peer were not observed downstairs, appearing as if [R1] and [R1's] peer AWOL'd out of a bedroom window. [R1] did not present with any precursor behaviors to indicate this action, and participated in all of programming...At approximately 2:55am [R1] and [R1's] peer were located by the [Phoenix] Police Department and were transported to the BHRF, Upon arrival staff searched [R1] for contraband coming into the home, in which a lighter and a substance weight scale was found on [R1's] peer...BHRF updated [R1's] safety crisis plan, reviewing all risks involved, healthy and appropriate coping skills to ensure that [R1] understands the safety risks involved with AWOL behavior and unhealthy choices to eliminate future risks. Staff processed the risk taking behavior of being AWOL and of potential substance abuse. [R1] will be taken...for a urinary analysis. BHRF notified [R1's] guardian immediately of the AWOL and stayed in communication with any updates. BHRF left a voicemail for [R1's] JPO. BHRF called...police to notify of [R1's] return and to confiscate the paraphernalia..." The document was signed by E2 on October 30, 2025, and E1 on October 31, 2025. 4. A review of the facility documentation revealed a document titled, "Incident Report Form," dated October 31, 2025. The document stated, "...On the evening of 10/31/2025 at approximately 6:05pm [R1] chose to AWOL with a peer. There was no precursor to [R1] going AWOL. [R1] returned from a previous AWOL and had processed the negative impact and risk taking behavior of going AWOL and potential substance use as [R1] had returned with observed red eyes...[R1] was taken to...perform a urinary analysis. [R1] safety planned and stated what interventions and coping skills [R1] could use to prevent a future AWOL. [R1] chose to leave regardless off [sic] this processing and safety planning...BHRF will update [R1's] safety crisis plan, reviewing all risks involved, healthy and appropriate coping skills to ensure that [R1] understands the safety risks involved with AWOL behavior and unhealthy choices to eliminate future risks. Staff processed the risk taking behavior of being AWOL and of potential substance abuse. [R1] will be taken...for urinary analysis upon [R1's] return. BHRF notified member's guardian immediately of the AWOL and will stay in communication with any updates. BHRF left a voicemail for [R1's] JPO. BHRF called...police to notify of [R1's] AWOL..." The document was signed by E1 and E2 on October 31, 2025. 5. A review of facility documentation revealed electronic communication dated December 4, 2025. The document stated, "...Last night at approximately 6:10pm, [R1] came to the office asking to process with staff. [R1] stated they wanted to AWOL from the facility. When asked why, [R1] stated that [R1] had 'messed up' and had too many mistakes to overcome and that [R1] was struggling with knowing what to do next. Staff encouraged [R1] to think positively and motivate [R1's] self to make positive behavioral changes instead of allowing this negative mindset to cause [R1] to make more decisions that would land [R1] in bigger trouble. Staff explained that once [R1] did a presentation, [R1] could work [R1's] consequences off as a way of motivation. [R1] asked what staff would do if they broke into the cabinet to retrieve their bag of confiscated items. Staff immediately moved in front of the cabinet to deter [R1] from breaking in. [R1] reiterated that they had already messed up. Staff asked how [R1] believed [R1] had messed up. [R1] showed [R1's] ankle and told staff that [R1] had cut off their ankle monitor earlier in the day when [R1] was working on a craft. [R1] then left the office and went out back. Support staff followed [R1] outside, and [R1] hopped over the wall at approximately 6:20pm. We followed AWOL protocol and called Glendale Police Department to notify them of AWOL. I called [guardian] and [court] to update them immediately following. Police arrived at the facility at 7:15 to take down [R1's] information. Should [R1] return we will update [R1's] crisis safety plan to assist [R1] in managing impulsivity and negativity when met with accountability..." 6. A review of the facility's policies and procedures revealed a document titled, "Unauthorized Absence/AWOL (Absence without Leave)." The document stated, "...Miss A's will take all precautions to limit a member from leaving the premise or community outing without authorized permission. If a member chooses to leave the premise or community outing without proper authorization, the administrator shall immediately notify the appropriate state and local law enforcement officials, the parent or legal guardian, the Child Family Team, and if under court jurisdiction, the appropriate court/JPO of the absence by telephone and email. Miss A's will treat each AWOL unique to the member's needs. To ensure the health, safety and welfare of all members in the milieu, all staff receive training to identify residents who are potentially at risk for AWOL. This information will be documented in the member's record. Miss A's will consider member AWOL if/when the member has left the home without permission. Miss A's will report if the member is danger to self, experiencing suicidal ideation, self-harm attempts, substance, etc.; danger to others, intent to hurt others, has means to hurt others, etc.. Miss A's BHT will immediately follow and keep in line of sight in attempt to de-escalate the member and re-direct back to the BHRF and/or community outing. If the member leaves the immediate neighborhood the BHT will not continue to follow the member for the safety of the member, BHT and community...If a member has reoccurring AWOL member will be evaluated by the administrator/designee or clinical supervisor/BHP/Team to determine if the member will remain at Miss A's for least restrictive environment or if a higher level of care is needed to keep the member safe in a more restrictive placement, higher level of care. BHRF will request a staffing if AWOL is a patterned behavior." 7. In an interview, E1 reported if personnel members witness a resident AWOL the facility, they will follow the resident, attempt to re-direct the resident to come back, and keep the resident in their line of sight if the resident stays in the surrounding neighborhood. E1 reported if a resident is running into an apartment complex or out into the street, neither personnel member, or police, will chase them due to safety risks for the resident, personnel, and the community. E1 reported to mitigate AWOLs at the facility, E1 had installed alarms on the doors that are activated at night, bells that hang from the door knobs to alert when someone goes in or out, and alarms on the windows. E1 reported the residents can remove the window alarms. E1 reported personnel members do room checks at night about every 45 minutes. 8. In an interview, E1 reported on the night of October 30, 2025, a personnel member did rooms checks at 10:00 PM, finding R1 in R1's room. E1 reported when the personnel member checked again at 10:45 PM, R1 was not in R1's room or anywhere else inside the facility. E1 reported cameras and the outside areas were checked which led them to believe R1 AWOL'd out of the bedroom window. 9. In an interview, E1 reported each time a resident AWOL's personnel will always meet with the resident upon return to update their safety crisis plan with them, which includes any triggers leading up to the resident wanting to AWOL, any interventions that could be helpful in the future, and coping strategies for managing and minimizing stress. E1 reported this was completed with R1 on October 30, 2025 and October 31, 2025 after both separate incidents. 10. In an interview, E1 reported after R1 AWOL'd on December 3, 2025, the facility made the decision to discharge R1 as they felt R1 needed a higher level of care than the facility could provide. E1 reported the population the facility serves often has an AWOL risk. 11. In the exit interview, E1 reported to disagree with the violation, and no further comments or documentation were provided. This is a repeated violation from the May 1, 2025 compliance inspection.


summary: Complaint - 9/26/2025

raw_content: No deficiencies were found during the on-site investigation of complaint 00146067 conducted on September 26, 2025.