Facility Evaluation Report

On 10/23/2025 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit regarding an incident report received by the Department on 12/11/2023 . LPA met with Licensee, Josefina “Penny” Gardner. Licensee later had to leave and provided authorization for Caregiver, Sinforosa Arawiran , to sign the report. LPA explained the purpose of the visit.

While LPA was conducting a complaint investigation ( #15-AS-20240202150258 ) on 10/23/2025, LPA sought clarification as to why the night shift staff did not complete an assessment on Resident 1 (R1) after R1 experienced a fall during the early morning hours.

Review of the facility’s incident report dated 12/09/2023 revealed that R1 fell at approximately 3:20 AM . The report indicated that Staff 2 (S2) assisted R1 from the floor and placed R1 back into bed. The report also noted that R1 had a history of hip surgery .

LPA interviewed Staff 1 (S1) who stated that S2 was able to assist R1 back into bed and completed an assessment by checking for bruising, skin tears, and observing for pain or discomfort.