Eldorado West Retirement Community.

Statement of Deficiencies License #: 2140 Compliance Determination # 71548 Plan of Correction ELDORADO WEST RETIREMENT COMMUNITY Completion Date Paget of6 Licensee: ELDORADO WEST INC 02/03/2026 You ate required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 01/21/2026 and 01/26/2026 of: ELDORADO WEST RETIREMENT COMMUNITY 1010 SW 134th St Burien, WA 98146 The following sample was selected for review during the unannounced on-site visit: 9 of 88 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Steven Garrett, LTC Licensor Jane Hermano, NCI From: DSHS, Home and Community Living Administration 20425 72nd Avenue S, Suite 400 Kent, WA 98032 6/2 ‘B}ISQOM JO}EDO7] BU} JO} SBDIAIAS Bed jeljUuepisey Aq paiedeisd sem JUSLUNDOP Siu @2,03.2026 12:02:87 State of Washington a Statement of Deficiencies License #: 2140 Compliance Determination #71546 Plan of Correction ELDORADO WEST RETIREMENT COMMUNITY Completion Date Page2 of6 Licensee: ELDORADO WEST INC 02/03/2026 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Quan ornare 02-03-2026 G Residential Care Services Date | understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. (al (het 02-00: Uy Administrator (or Representative) Date WAC 388-78A-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened_for tuberculosis within three days of amoloyment This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 1 of 6 staff (Staff C) was screened for tuberculosis (TB) within three days of employment. This failure placed 88 residents at risk of contracting an airborne and contagious respiratory disease. Findings included... Review of facility’s Characteristics Roster showed the facility provided assisted living services to 88 residents. Review of facility's personnel records showed the facility hired Staff C, Caregiver, on 08/07/2025. Review showed from 08/07/2025 through 01/26/2026, Staff C worked at the facility. Staff C provided care and services for residents. Documentation showed Staff C was screened for TB on 12/11/2025, 126 days after employment. During an interview on 01/22/2026 at 10:15 AM, Staff A, Executive Director/Administrator, stated that they were aware of the TB screening requirements. Staff A stated that they were unaware that Staff C was not screened for TB within three days of employment. ‘B}ISQOM JO}EDO7] BU} JO} SEDIAIAS Ged jeljUuepisey Aq paiedeid sem JUSLUNDOP Siu 02.03.2826 12:02:07 State of Washington Statement of Deficiencies License #: 2140 Compliance Determination # 71548 Plan of Correction ELDORADO WEST RETIREMENT COMMUNITY Gompletion Date Page3 of6 Licensee: ELDORADO WEST INC 02/03/2026 Plan/Attestation Statement | hereby certify that | have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, ELDORADO WEST RETIREMENT COMMUNITY is or will be in compliance with this law and / or regulation on (Date)_62°20-24 In addition, | will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) (ok fas Date 62 ba: ZU WAC 388-112A-0611 Who in an assisted living facility is required to complete continuing education training each year, how many hours of continuing education are required, and when must they be completed? : (1) The continuing education training requirements that apply to certain individuals working in assisted living facilities are described below. (a) The following long-term care workers must complete 12 hours of continuing education by their birthday each year: (iii) A certified nursing assistant; WAC 388-112A-0720 What are the CPR and first-aid training requirements? (2) Assisted living facilities. (a) Assisted living facility administrators who provide direct care and long-term care workers must have and maintain a valid CPR and first-aid card or certificate within thirty days of their date of hire. (b) Licensed nurses working in assisted living facility must have and maintain a valid CPR card or certificate within thirty days of their date of hire. WAC 388-784-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. This requirement was not met as evidenced by: Based on interview and record review the facility failed to ensure 2 of 6 staff (Staff A and Staff E) completed and maintained all required training to perform their job duties and responsibilities. This failure placed 88 residents at risk of unmet care needs from ‘@JISQOM J0}E907] OU} JOJ SEDIAIES aed JeNUepIsey Aq pesedeid sem jUaLUNDOp SIU, 02.03.2026 12:02:07 State of Washington Statement of Deficiencies License #: 2140 Compliance Determination # 71548 Plan of Correction ELDORADO WEST RETIREMENT COMMUNITY Gompletion Date Page4 of6 Licensee: ELDORADO WEST [NC 02/03/2026 staff with incamplete training: Findings included... Review of the facility's Characteristics Roster showed the facility provided assisted living services to 88 residents. Review of facility's personnel records showed the facility hired Staff A, Executive Director/Administrator, on 02/13/2023; and Staff E, Caregiver, on 07/12/2023. FIRST AID AND CARDIOPULMONARY RESUSCITATION (CPR) Review of Staff A’s undated personnel records showed Staff A provided direct care for residents from 02/13/2023 through 01/26/2026. The records showed that Staff A was a Licensed Practical Nurse (LPN). The records showed documentation in Staff A’s records that Staff A’s required CPR and First Aid training expired on 12/2025. CONTINUING EDUCATION (CE) Review of Staff E’s undated personnel records showed Staff E provided direct care for residents from 07/12/2023 through 01/26/2026. The records showed that Staff E was a Certified Nursing Assistant (CNA). There was no documentation in Staff E’s records that showed Staff E completed the required 12 hours of CE between their birthdays, 08/11/2024 and 08/11/2025. During an interview on 01/22/2026 at 10:15 AM, Staff A stated that they were aware of the First Aid/CPR and CE training requirements. Staff A stated that they were aware their First Aid/CPR training had expired. Staff A stated that they were unaware Staff E had not completed the required 12 hours of CE requirements. Plan/Attestation Statement | hereby certify that | have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, ELDORADO WEST RETIREMENT COMMUNITY is or will be in compliance with this law and / or regulation on (Date)_ 02-20 -Z2U In addition, | will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Al behor Date 02 -00-2Y ‘@JISGOM J10}E907] BU} JOJ SEDIAIES aed JeNUepIsey Aq pesedeid sem jueLUNDOp SIU, 02.03.2026 12:82:87 State of Washington ss sss. Statement of Deficiencies License #: 2140 Compliance Determination # 71548 Plan of Correction ELDORADO WEST RETIREMENT COMMUNITY Gompletion Date Page5 of6 Licensee: ELDORADO WEST [NC 02/03/2026 WAC 388-78A-2400 Protection of resident records. The assisted living facility must: (2) Maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapters 70.02 and 70.129 RCW; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 20 of 20 Medication- packaging cards (Medication card 1 through Medication card 20) which contained resident's identifiable health infarmation were pratected from unauthorized access by other people. This failure placed the residents’ confidential health records at risk for access from unauthorized individuals. Findings included... Note: RCW 70.129.050 Privacy and confidentiality of personal and medical records. The resident has the right to personal privacy and canfidentiality of his or her personal and clinical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. This does not require the facility to provide a private room for each resident however, a resident cannot be prohibited by the facility from meeting with guests in his or her bedroom if no roommates object. Review of the facility’s undated policy titled, “Resident Rights-Our Resident's Bill of Rights”, showed that resident's personal and medical records were treated as confidential.

—: WA DSHS report: Inspections (09/2024)

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. N/A This document was prepared by Residential Care Services for the Locator website.