- Utah inspectors hadn't observed Safe and Sound Services' clients for nearly two years, a KSL investigation revealed on Friday.
- The investigation came after three disabled men died on Feb. 6 after being left in a running van.
- Isaiah Vaughn Pulu faces murder charges, with carbon monoxide poisoning likely causing the deaths.
SALT LAKE CITY — Utah inspectors had not observed clients receiving care at Safe and Sound Services for nearly two years before three disabled men died after being left for hours in a running van, according to state licensing records and charging documents.
On Feb. 6, a Safe and Sound Services employee left "three clients in a running vehicle unattended" inside his garage and went into his home, according to a notice of emergency agency action issued by the Utah Department of Health and Human Services. Hours later, the three men were found unresponsive and were pronounced dead by medical personnel.
Prosecutors have charged 25-year-old Isaiah Vaughn Pulu with three counts of murder. Charging documents allege Pulu was supposed to take the men on an approved outing but instead drove home, parked in his garage and left the van running for about 4½ hours while he went inside to eat and watch TV.
Court documents identify the victims as 25-year-old Colton Warren Moser, 22-year-old Mosa'ati Moa and 39-year-old Tim Jones. Investigators say the men, who relied on caregivers, likely died from carbon monoxide poisoning.
KSL Investigators reached out to Safe and Sound Services for comment on the deaths and the inspection history. The facility did not respond.
As the criminal case moves forward, KSL Investigators reviewed state inspection records that show regulators had not witnessed hands-on care at the provider's facility since March 2024.
March 2024 inspection documented clients on-site
The most recent inspection where state licensing staff documented clients on-site occurred March 12, 2024, at Safe and Sound Services' previous Magna location.
According to the inspection checklist, 10 clients were present during that visit. The program was licensed at that time to serve 33 clients.
Inspectors documented three noncompliant findings, including a missing first aid item, a background check issue and incomplete suicide risk training. Records indicate those issues were corrected while inspectors were on-site.
That March 2024 inspection is the last documented time regulators directly observed the provider delivering hands-on care to disabled adults.
Relocation doubled capacity but involved no client observation
Later in 2024, Safe and Sound Services relocated to a larger facility at 1574 W. 1700 South in Salt Lake City.
A Dec. 20, 2024, pre-license inspection is described as a "physical site inspection only." Records show no clients were present during that visit. As a result, inspectors did not observe staff-client interactions, supervision practices or transportation procedures in real time.
Despite the limited scope, the state approved the new location to serve up to 62 clients — nearly doubling the provider's previous licensed capacity.
2025 annual inspection also found no clients present
On Feb. 18, 2025, Utah regulators conducted the program's annual announced inspection at the Salt Lake City location.
The inspection checklist shows zero deficiencies. It also documents that zero clients were present at the time of the visit.
Without clients on-site, inspectors did not observe supervision, staffing ratios, behavioral supports or transportation practices — the same category of service involved in the fatal incident — in the nearly year leading up to the deaths.
State acknowledges limitation when clients aren't present
In an interview with KSL Investigators, Shannon Thoman-Black, director of Utah's Division of Licensing and Background Checks, acknowledged inspectors cannot evaluate direct care if clients are not there.
"If there are not clients being served, that isn't something we can evaluate," Thoman-Black said.
She said inspections are designed to verify policies, documentation, staff training, background clearances and administrative readiness.
"This is why we go into these providers on a regular basis. This is why we have the ability for people to register complaints for us to inspect. So it is part of a whole system," she said.
Related:
Caregiver left disabled men in running van while he ate, watched anime, murder charges say
A caregiver transporting three disabled men who allegedly left them in running van while he ate and watched TV was charged Friday with three counts of murder.Transportation — the activity during which the three men died — is regulated under the day treatment license.
"Day treatment is one complete license; transportation is generally a part of that license," Thoman-Black said.
However, because no clients were present during the December 2024 relocation inspection or the February 2025 annual inspection, transportation practices were not observed in real time during either visit.
Thoman-Black said employees with direct access to clients must undergo background checks that include criminal history, sex offender registry, child abuse registry and adult protective services registry reviews. She declined to discuss details about the charged employee, citing the ongoing investigation.
Emergency action issued after deaths
Following the triple fatality, DHHS issued an emergency action placing conditions on Safe and Sound Services' day treatment license.
The order requires the provider to stop admitting new clients, retrain all staff on supervision and transportation requirements, cooperate with investigators and submit to increased monitoring inspections billed at $393.37 per visit.
The department may pursue additional action — including possible license revocation — after its investigation concludes.
DHHS has not released how many clients were being served on the day of the incident.
How to review state inspection records
State inspection reports and licensing records for Safe and Sound Services are publicly available through the Utah Department of Health and Human Services Division of Licensing and Background Checks.
To search for a provider, click on "health facilities," scroll down and select "find a facility." Users can search by facility name. If a provider does not immediately appear, it may be listed under the city or county where it is located.
Inspection checklists, compliance findings and enforcement actions are posted within the provider's record.
Have you experienced something you think just isn't right? The KSL Investigators want to help. Submit your tip at investigates@ksl.com or 385-707-6153 so we can get working for you.
