Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00276419 Renewal 10/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59Emergency numbers on a sticker located on the telephone on a staff's desk located in the program area were rubbed off the phone and unable to be read. This was corrected on the day of the inspection by staff placing a new, legible sticker on the phone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone.A new legible emergency sticker with all current emergency phone numbers was placed on the desk phone on 10/22/2025 during the inspection walk through and corrected. Attachment #1 10/22/2025 Implemented
2390.151(a)Individual 2's two most recent annual assessments are dated 08/12/2024 and 10/23/2025, which exceeds the annual timeframe.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The Program Specialist has been re-trained on compliance/due dates of assessments. Attachment #1, 1a 11/04/2025 Implemented
2390.21(u)Individual Rights were presented to Individual 1 on 01/25/2024 and then on 07/17/2025, which exceeds the annual timeframe.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.All employees were trained on 11/4/25 on individual rights and the need to complete it at admission and annually. Attachment #1, 1a 11/04/2025 Implemented
2390.21(u)Individual Rights were presented to individual 2 on 01/25/2024 and then during the inspection on 10/23/2025, which exceeds the annual timeframe.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.All employees were re-trained in individual rights on 11/4/25 and are aware individuals should receive this information on an annual basis. Attachment #1, 1a 11/04/2025 Implemented
SIN-00233580 Renewal 10/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.67The trim surrounding the door in the foyer exit from program room one was off the wall and leaning up against the wall. Also, a part of the trim was missing. The violation was corrected during the inspection.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.Safe and sanity conditions shall be provided while handling supplies, packaging products and carrying out work functions. floors, walls, and surfaces shall be in good repair. The maintenance department was immediately contacted to replace the door trim that was not replaced in the doorway in the foyer exit from the program room one. The trim was replaced in the doorway. 10/11/2023 Implemented
SIN-00213061 Renewal 10/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.71(a)There was no ventilation by a operation mechanical (fan) or window in the woman and men's bathroom.Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation.Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation. The maintenance team arrived shortly after Licensing on 9/7/2022 and the ventilation was fixed the same day in the men¿s room. The women¿s room was not able to be fixed without a new motor. A new motor was ordered and the maintenance team replaces the motor on 10/17/2022 when the motor arrived. 12/22/2022 Implemented
SIN-00253855 Renewal 10/16/2024 Compliant - Finalized