Facility Evaluation Report

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management to deliver findings for a self-reported sexual assault. The LPA arrived at 12:29PM and met with Executive Director (ED) Lance Shenk. Entrance interview conducted.

On 01/27/2026, the Department received a notification of an alleged staff on resident sexual assault that reportedly occurred a week prior.

On 01/28/2026, the LPA conducted an initial visit. Beginning at 9:43AM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. Between 02/04/2026 and 05/15/2026, the Department interviewed the ED, Resident #1 (R1), family, and staff.

During today’s visit, the LPA and ED conducted a physical plant tour at 12:40PM, and no immediate concerns were observed. The following was then determined:

It was reported that Staff #1 (S1) solicited R1 to leave the facility over the course of multiple days, transported R1 to S1’s home, and sexually assaulted R1. It was further revealed that R1 initially disclosed the assault to Staff #2 (S2) and Staff #3 (S3) on 01/25/2026 and 01/27/2026. However, neither staff reported the allegation to the facility’s On Duty Nurse nor the ED at that time. S2 and S3 stated they believed they were required to report directly to the ED in-person and therefore did not report the alleged abuse immediately. R1 also reported the allegation to the On Duty Nurse on 01/27/2026, at which time the On Duty Nurse immediately notified the ED.