Stephanie Alderete Home Care, LLC.

“Based on record review, documentation review, and interview, the manager failed to ensure compliance with Arizona Revised Statute (A.R.S.) § 36-411. The deficient practice posed a risk if E1 was a danger to a vulnerable population. Findings include: 1. A record review of E1's personnel record revealed, E1 was the documented manager of the facility. 2. A record review of E1's personnel record revealed, a copy of an Arizona Department of Public Safety (DPS) Fingerprint Clearance Card was located in E1's file. A documentation verifying the validation of the fingerprint card was not available for review.   3. An online check by the Compliance Officer on January 8, 2026, of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed that E1 had a valid DPS fingerprint Clearance Card.   4. In an interview, E1 acknowledged that the manager failed to ensure E1 provided compliance with the requirements in A.R.S. § 36-411(C).”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services.   Findings include:   1. A record review of the personnel file for E3 revealed, the new employee checklist and the caregiver skills and knowledge checklist were blank.   2. A documentation review of the facility's Policies and Procedures titled, "Staffing and Record Keeping" stated, "Establishing Personnel Record filing for the employee's file are the following: 5. Verification of skills and knowledge 6. Employee Orientation form."   A documentation review of the facility's Policies and Procedures titled, "Skills and Knowledge" stated, " All personnel who work in assisted living facility are required to have specific knowledge and demonstrate their understanding on specific topics including but not limited of the following: Abuse prevention, Resident Rights, Dementia care, Infection control, Fall prevention and fall recovery, TB risk assessment training CPR and First Aid, Emergency preparedness, Advance Directives, Service Plans, Proper Documentation."   4. In an interview, E1 acknowledged the manager did not ensure E3's caregiver skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, according to policies and procedures.”

“Based on record review, documentation review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113.   Findings include: 1. A record review of E1's personnel record revealed, the employee did not have a TB screening assessment form nor negative two-step TB tests available for review. 2. A documentation review of the facility's Policies and Procedure titled, "TB Testing and Risk assessment" stated, "The TB test must be Both administered AND read prior to the individual being accepted as a resident or as an employee, providing services to residents, or moving into the facility, as appropriate."   3. In an interview, E1 acknowledged, the manager did not ensure E1 provide a TB screening assessment form nor negative two-step TB tests. upon hire and annually prior to providing services at or on the behalf of the assisted living facility.”

“Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for two of three personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. A record review of E1's personnel record revealed, the employee's date of birth, contact telephone number, starting date of employment, qualifications, education and experience, orientation and in-service education, license or certification, evidence of freedom from Tuberculosis, and compliance with A.R.S. § 36-411(A), were not documented in the employee record. 2. A record review of E3's personnel record revealed, the employee's contact telephone number, starting date of employment, qualifications, education and experience, orientation and in-service education, license or certification, and evidence of freedom from Tuberculosis, were not documented in the employee record. 3. A documentation review of the facility's Policies and Procedures titled, "Staffing and Record Keeping" stated, "Establishing Personnel Record filing for the employee's file are the following: 5. Verification of skills and knowledge 6. Employee Orientation form."   A documentation review of the facility's Policies and Procedures titled, "Skills and Knowledge" stated, " All personnel who work in assisted living facility are required to have specific knowledge and demonstrate their understanding on specific topics including but not limited of the following: Abuse prevention, Resident Rights, Dementia care, Infection control, Fall prevention and fall recovery, TB risk assessment training CPR and First Aid, Emergency preparedness, Advance Directives, Service Plans, Proper Documentation." 4. In an interview, E1 acknowledged the manager failed to ensure E1 and E3's personnel records contained the required components listed in R9-10-806.C.1.a-c.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious Tuberculosis before or within seven calendars after the resident's date of occupancy as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents.   Findings include:   1. A record review of R1’s medical records revealed, documentation of a TB screening and risk assessment form and a negative TB test, was not available for review. A record review of R2's medical records revealed, documentation of a TB screening and risk assessment form, was not available for review.   2. A documentation review of the facility's Policies and Procedure titled, "TB Testing and Risk assessment" stated, "The TB test must be Both administered AND read prior to the individual being accepted as a resident, providing services to residents, or moving into the facility, as appropriate."   3. In an interview, E1 acknowledged the manager failed to ensure R1 and R2 provide documentation of freedom from infectious Tuberculosis (TB) prior to or within seven calendar days of admission.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a resident has a service plan that was established, documented, and implemented that: when initially developed and when updated, was signed and dated by: the resident or resident’s representative, and the facility manager.  The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A record review of R1's medical records revealed, the resident received Personal Care services.   2. A record review of R1's medical records revealed, the resident's service plan dated June 28, 2025 was signed but not dated by the resident or resident's representative and facility manager, who reviewed the service plan. It was reviewed by an RN on May 5, 2025. 3. A record review of R2's medical records revealed, the resident received Directed Care services. 4 . A record review of R2's medical records revealed, the resident's service plan for November 2025 was not signed nor dated by the facility manager. 5. In an interview, E1 acknowledged the manager failed to ensure R1 or R1’s representative and the facility manager, signed and dated the updated service plans.”