How to individually submit a complaint in Arizona.

Submitting Complaints to Arizona Department of Health (AZDHS)

Information:

• ESAAlliance has submitted the compiled Anonymous Mass Complaint Data and written testimonies to the Arizona Department of Health.

• For those survivors who are interested in submitting a copy of their complaint to Arizona Department of Health, we have outlined steps on how to do so and what you can expect from the investigation with the Arizona Department of Health.

• The Arizona Department of Health might contact you for further details, dates, times and explanations. They might ask about any potential evidence, like photos, recordings, screenshots, journal entries, client records, or police reports.

• ESAAlliance will assign you a Survivor Number, which is how you can be identified to the Arizona Department of Health so they can cross reference your individual complaint to the mass complaint. Email liz@esaalliance.org if you need to find out your survivor number.

Arizona Department of Health Complaint FAQ:

• WHAT CONSTITUTES A COMPLAINT?

  Complaints are related to quality of life and quality of care, including residents’ rights, abuse, neglect, dietary problems, staffing and environmental concerns.

• WHO CAN FILE A COMPLAINT?

  Anyone with knowledge or concerns about an assisted living, behavioral health, long term care or medical facility may file a complaint in writing. Most complaints are filed by residents, family members, concerned friends, a guardian of resident, facility staff members, other health professionals and ombudsman. It is most important that the complainant provide as much specific information as possible including the name and address of the facility, date and time of events indicated in the complaint. It is imperative that complaints be reported timely since it is difficult to effectively gather information surrounding an incident that occurred months before.

• WHY REPORT IN WRITING?

  The complaint form is available 24 hours a day, seven days a week. There is no time spent on the telephone. It ensures that the information you give about your complaint will be more accurate and complete.

• HOW ARE COMPLAINTS INVESTIGATED?

  Complaints are assigned to a surveyor and investigated. The investigation may include a review of records, interviews with staff and residents, and observation of the care of the residents. If names have been provided in the complaint, those persons will be contacted. An investigation of a complaint may result in a complete compliance survey being conducted.

• HOW WILL I KNOW THE RESULTS OF MY COMPLAINT?

  Complainants and the facility are notified of the findings of each investigation. The name of the complainant is not shared with the facility so confidentiality is protected.

• HOW DO I FILE A COMPLAINT?

  Scroll down to see the example of how to fill out the complaint form. Complete all the information that the form asks for that you are able to provide. Please remember the more information that you can provide only helps the surveyor investigate your complaint in a timely manner.

Step 2. - FOR PATHWAY

Enter the Pathway Program’s information as listed as a Medical Facility. It should auto-fill, but if it doesn’t their facility info is:

Name: The Pathway Program

License Number: CSLG7119

Address: 4820 South Mill Avenue, Suite 204

City: Tempe

State: Arizona

Zip: 85282

Step 2. - FOR STEP TWO RECOVERY

Enter the Step Two Recovery Center’s information as listed as a Medical Facility. It should auto-fill, but if it doesn’t their facility info is:

Name: Step Two Recovery Center

License Number: BH2607

Address: 3771 East Brooks Farm Road

City: Gilbert

State: Arizona

Zip: 85298

Step 4.

You have the option to remain anonymous while submitting your complaint. If you choose to be anonymous, you will need to provide your reasoning or concerns for protecting your anonymity. Write in as much as you want.

You will have to provide your legal name to Arizona Department of Health whether or not you choose to remain anonymous.

Select “No” if you don’t want or need to be anonymous.

Step 4. - Continued

Provide the best email address for you to verify your complaint submission and leave a phone number for them to be able to contact you with more questions.

Check “PATIENT/CLIENT” or “FORMER STAFF MEMBER” (If you were a patient and staff member of an Arizona program, select both.)

LET YOUR FAMILY MEMBERS KNOW THAT THEY CAN SUBMIT THEIR OWN WRITTEN COMPLAINTS

Check the final box below (not shown) that states: *By submitting this form electronically, I state that I have read the complaint contents and the statements are true by my personal knowledge or I believe them to be true.

Click SEND to submit your complaint. Check your email to verify your complaint.

Reporting Licensed Counselors in Arizona

This entire process is done online through an editable PDF on the Arizona State Board of Behavioral Health Examiners website.

This form is only for licensed counselors in The Pathway Program.

The only two people licensed through AZBBHE is Josh Azevedo and Kim Miller.

Step 2.

First fill out the information for either licensed counselor:

Name: Joshua Azevedo

Address: 4820 S Mill Ave #101, Tempe AZ, 85282

Phone: (480) 921-4050

License Number: LISAC-1644

Name: Kimberly Miller

Address: 4820 S Mill Ave #203, Tempe AZ, 85282

Phone: (480) 600-0539

License Number: LISAC-11696 & LCSW-12950

Then continue to fill out your personal information. Check the box “No” if you are submitting this complaint for yourself.

Check “YES” if you have personally confronted Josh or Kim about your concerns or complaint. If not, check “NO”.

Check YES to attach documentation. You can describe it as a personal complaint form or ESAAlliance Mass Complaint Form. Please include other documentation if you have any, such as records, text messages, emails, pictures, etc.