Inspection Report Summary
Most inspections found deficiencies, with several substantiated complaints related to medication management, staffing shortages, and facility maintenance issues. The most recent report from August 6, 2025, cited a deficiency for water temperatures in resident bathrooms being below the required minimum, posing a health and safety risk. Serious medication errors occurred in early 2024, including incidents that led to hospitalizations and a stroke, resulting in staff terminations and enforcement actions including a civil penalty in February 2024. Other notable issues over time included unsafe hot water temperatures, unsecured medications, pest infestations, malfunctioning call systems, and unsecured gates, though many complaint investigations were unsubstantiated. While some corrective actions have been taken, such as staff training and repairs, the facility’s record shows ongoing challenges with resident safety and environmental maintenance.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a August 2025 inspection.
Census over time
Inspection Report
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Accompanied Licensing Program Analyst on facility tour and was present during exit interview |
| Monica Aguirre | Assistant Executive Director | Provided information regarding medication training and facility staffing |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Assistant Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on report |
| Melanie Washington | Executive Director | Participated in exit interview |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Administrator | Met with Licensing Program Analysts during inspection. |
| Melanie Washington | Administrator/Executive Director | Notified and assisted with the visit; received exit interview. |
| Sergio Mendoza | Dining Services Manager | Greeted and granted entry to Licensing Program Analysts. |
| Eboni Bentley | Licensing Program Analyst | Conducted inspection and signed report. |
| Jenifer Tirre | Licensing Program Analyst | Conducted inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and made observations regarding the cable TV issues. |
| Monica Aguirre | Assistant Executive Director | Met with the Licensing Program Analyst during the investigation and provided information about the cable TV service. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Melanie Washinton | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection visit |
| Melanie Washington | Executive Director | Facility representative who assisted with the visit |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Administrator | Facility administrator present and assisted with the visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Enforcement| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during visit and exit interview; provided with report and civil penalty assessment |
| Rosie Quiroz | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Facility Administrator who confirmed missed medication doses and conducted internal investigation |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative met during the inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the licensing program and cited in the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative interviewed during investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit and follow-up |
| Melanie Washington | Executive Director | Facility representative who assisted during the investigation |
| Monica Aguirre | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Melanie Washington | Executive Director | Facility administrator present during the investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the inspection and involved in the exit interview. |
| Jessica Cho | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Melanie Washington | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and observed the gate latch issue. |
| Melanie Washington | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during the visit |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sarah Cleesen | Administrator | Named in allegations regarding responsiveness to responsible party concerns |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility administrator met during investigation |
| Brenda Bravo | Resident Care Director, L.V.N. | Participated in exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation and was the subject of the impairment allegation |
| Sarah Cleesen | Administrator | Facility administrator implicated in the impairment allegation |
| Sheila Santos | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Gail Blessum | Business Office Director | Met with Licensing Program Analyst during investigation |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during investigation and exit interview |
| Juli Sanchez | Vibrant Life Director | Met with Licensing Program Analyst during investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Cleesen | Administrator | Facility administrator named in report header |
| Gail Blessum | Business Office Director | Met with Licensing Program Analyst during visit |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during visit and participated in exit interview |
| Juli Sanchez | Vibrant Life Director | Met with Licensing Program Analyst at start of visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative who assisted during the investigation and exit interview |
| Gail Blessum | Business Office Director/Manager | Met with Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation visit and report |
| Melanie Washington | Executive Director | Facility representative interviewed during the investigation |
| Judi Williams | Resident Care Director | Notified Resident #1 of level of care increase via email |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Administrator | Facility administrator involved in the investigation and exit interview |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during visit and indicated correction of deficiencies |
| Kathrina Chin | Licensing Program Analyst | Conducted the site visit |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Heather Yost | Administrator | Facility administrator named in the report and responsible for submitting plans of correction |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the visit and received the amended report. |
| Kathrina Chin | Licensing Program Analyst | Conducted the visit and substantiated the complaint. |
| Sheila Santos | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Building Services Director | Interviewed regarding key issuance to resident |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Heather Yost | Executive Director | Named in relation to the auditory call system malfunction and efforts to fix it |
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst and provided statements regarding medication technician training and corrective actions |
| Sarah Cleesen | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and received report |
| Stephanie Guerrero | Resident Care Coordinator | Interviewed during investigation |
| Jessica Thielmann | Resident Care Director | Interviewed during investigation |
| Julie Sanchez | Activities Director | Interviewed during investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative interviewed during investigation and named in findings |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Interviewed during investigation; acknowledged pest issue and plan of correction |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Staff 3 | Building Services Director | Reported seeing roaches in several resident apartments and scheduled extermination services |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Interviewed regarding telephone service and back entrance security deficiencies |
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during the Case Management visit and informed about overdue fees |
| Patricia Velazquez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Sheila Santos | Licensing Program Manager | Named in the report header |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Allison Marty | Vice President of Operations | Met during the informal conference and discussed staffing issues |
| Melanie Washington | Executive Director | Met during the informal conference and discussed staffing issues |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Andrea Nino | Business Office Director | Met with Licensing Program Analyst and Ombudsman during the visit and received a copy of the report. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Joan Johnson | Interim Executive Director | Provided information about staffing and medication issues during investigation. |
| Chantelle Hudson | Nurse Consultant | Provided list of residents who missed medications and informed doctors. |
| Allison Marty | Vice President of Operations | Stated that a Plan of Correction will be submitted and additional staff will be hired. |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Sarah Cleesen | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the resident and incident |
| Kathrina Chin | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the annual inspection and exit interview |
| Sarah Cleesen | Executive Director | Facility administrator met during inspection and exit interview |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Sarah Cleesen | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident report. |
| Kathrina Chin | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Heather Yost | Executive Director | Met with Licensing Program Analyst during the visit and involved in the incident discussion |
| Kathrina Chin | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Heather Yost | Administrator | Met with Licensing Program Analyst during the visit |
| Michelle Reed | Licensing Program Analyst | Conducted the annual inspection visit |
| Sheila Santos | Licensing Program Manager | Named in report header |
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