Inspection Reports for eliseo
1301 N Highlands Pkwy, Tacoma, WA 98406, WA, 98406
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 21, 2025, found no deficiencies after a follow-up to verify correction of prior fire safety issues. Earlier inspections showed a pattern of fire safety deficiencies, including missing documentation for sprinkler system inspections and physical fire safety maintenance problems. A substantiated complaint investigation in July 2025 related to fire safety resulted in citations, but the facility completed repairs and returned to compliance. Prior reports also noted an infection control deficiency during a COVID-19 outbreak in 2022, where staff were not wearing eye protection or testing all employees and residents. The inspection history shows improvement over time, with recent inspections clearing previous fire safety and infection control issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
51 residents
Based on a October 2025 inspection.
Occupancy over time
Inspection Report
Follow-Up
Census: 51
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire safety compliance.
Complaint Details
Complaint investigation conducted on 07/15/2025 due to a failed fire safety inspection. The facility had failed a reinspection on 05/20/2025. The complaint was substantiated with citations written. The facility completed repairs and was awaiting final report acceptance by the Fire Marshal.
Findings
The follow-up inspection on 10/21/2025 found no deficiencies. Previously cited deficiencies related to fire sprinkler system testing and maintenance were corrected, and the facility was brought back into compliance with the Washington state fire marshal requirements.
Deficiencies (1)
Failure to maintain compliance with State Fire Marshal codes for Long Term Care facilities, specifically missing fire sprinkler system documentation including last 5-year inspection/test report and FDC hydro test report.
Report Facts
Total residents: 51
Compliance Determination #: 62587
Compliance Determination #: 67511
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who conducted the complaint investigation and follow-up inspection. |
| Staff A | Maintenance Supervisor | Interviewed regarding fire sprinkler system testing and compliance status. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 06/12/2025 to assess compliance with regulatory standards.
Findings
The inspection found no deficiencies in the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Brunton | Regulatory QA Program Manager - Community Programs | Department staff who conducted the inspection |
| Shirley Grew | LTC Surveyor | Department staff who conducted the inspection |
| Cory Myers | NCI ALF Licensor | Department staff who conducted the inspection |
Inspection Report
Re-Inspection
Deficiencies: 9
Date: May 4, 2023
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the Eliseo assisted living facility to verify correction of previously cited fire safety violations.
Findings
The facility was found to have multiple unresolved fire safety violations including lack of required documentation for sprinkler system inspections, fire door inspections, fire/smoke damper testing, carbon monoxide alarm inspections, emergency lighting tests, and fire drills. Physical deficiencies such as multiple ceiling penetrations, missing self-closer on a fire door, and obstructed fire extinguisher cabinet were also noted.
Deficiencies (9)
Facility was unable to provide fire sprinkler system documentation including quarterly inspection reports for Q1, Q2, Q3 of 2022, last 3-year full flow trip test report, and last 5-year inspection/test report.
Storage room across from Apt. 117 has multiple ceiling penetrations around piping above storage rack located on corridor wall.
Unable to provide annual inventory records showing all resistance-rated construction was inspected/repaired in the last 12 months.
Unable to provide annual inventory records showing all fire-rated doors were annually inspected, tested and repaired in the last 12 months.
Unable to provide documentation showing that fire/smoke damper inspection and testing has been performed in the last four years.
Unable to provide documentation showing that monthly inspection of the facility's carbon monoxide alarms has been performed in the past 12 months.
Unable to produce documentation showing that monthly visual inspections of the facility's exit signs has been performed in the last 12 months.
Facility has failed to conduct and/or document fire drills in the past 12 months; staff stated drills have not been performed and previous records cannot be located.
Facility will be required to conduct a fire drill for each shift in May and June 2023, totaling three day shifts, three evening shifts, and three night shifts.
Report Facts
Fire drills required: 12
Fire drills to be conducted: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple inspection reports. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation following reports of a COVID-19 outbreak at the assisted living facility.
Complaint Details
Complaint investigation related to infection control due to a COVID-19 outbreak. The facility failed to meet Assisted Living Facility requirements regarding infection control.
Findings
The facility was found not to be wearing eye protection and was not testing all employees and residents for COVID-19 during outbreak status. The facility was educated on infection control practices and immediately instructed staff to wear eye protection and initiate testing for all staff and residents.
Deficiencies (1)
Facility not wearing eye protection and not testing all employees and residents for COVID-19 while in outbreak status.
Report Facts
Total residents: 51
Resident sample size: 1
Closed records sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aube | ALF NCI | Department staff who conducted the inspection and provided consultation |
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