Facility Evaluation Report

On 03/11/2026 at 5:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, David Clawson, and explained the purpose of the visit.

While conducting complaint investigation 15-AS-20251118152637 on 03/11/2026, LPA conducted record review and interviews. Based on record review, interviews, and documents obtained during the investigation, LPA determined the following:

1. Resident (R1)’s financial records for 2022 were not maintained at the facility. On 03/04/2026, Staff (S1) stated, “Our business took over operations on March 1, 2025. We do not have financial records for the information you requested back on 9/1/22.”

2. Community Care Licensing Division (CCLD) was not notified of fall incidents involving R1. Facility records indicate R1 sustained a fall on 03/17/2025, and four (4) additional falls on 07/10/2025 at approximately 3:15 AM, 4:30 AM, 4:45 AM, and 5:15 AM. Records further indicate that on 04/06/2025 a call pendant alert was activated with a documented response time of 161.9 minutes, after which R1 was sent out for medical attention. On 03/05/2026, Staff (S2) stated via email, “Unfortunately, we wouldn’t do a LIC 624 when a resident is not sent out. But we created an incident report documenting the incident and the resident refusing to be sent out.”