Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285370 Renewal 03/19/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a 5-gallon paint can that was unlocked in the basement. There were several OTC medications, such as, Pepcid, Nyquill, Tylenol, and Alka- Seltzer that were in a dining room cabinet unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals. The medications and paint can were moved to locked areas on 3/19. (Supporting Documents S1 and S2) 03/19/2026 Implemented
6400.64(a)The freezer in the basement was dirty and grimy.Clean and sanitary conditions shall be maintained in the home. The freezer was cleaned on 3/20 (Supporting Document S24). 03/20/2026 Implemented
6400.72(b)The window screen for the small dining room had a hole in it. Screens, windows and doors shall be in good repair. The Screen was repaired on 3/23 (Supporting Document S3). 03/23/2026 Implemented
6400.76(a)The left hallway cabinet's top drawer was not secure, as it would come completely out and fall to the floor if completely opened. Furniture and equipment shall be nonhazardous, clean and sturdy. The cabinet is not used by the individual and was removed on 3/23 (Supporting Document S28). 03/23/2026 Implemented
6400.76(c)The dining room chairs had paint that was warn-off. The arms that were not sturdy and the pegs were sticking out of them that made their use uncomfortable when the arm was rested on them.Furniture shall be comfortable and home-like. Replacement Chairs were ordered 4/7/26 and will be delivered 4/10/26 (Supporting Document S26). 04/10/2026 Implemented
6400.101One of the steps from the 2nd floor to the 3rd floor had items that partially obstructed the steps.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Items were moved from the steps on 3/19 (Supporting Document S25). 03/19/2026 Implemented
6400.105There were cleaning products stored in the warm boiler/furnace room that had instructions on their labels to be stored in a cool dry place.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The cleaning products were moved to locked areas on 3/19 (Supporting Documents S1 and S2). 03/19/2026 Implemented
6400.141(a)Individual #2's annual physical was completed on February 26, 2026 versus the January 8, 2025 one, which exceeded the 12-month requirement including the grace period. It was shared that the individual refused to get out of the car for an earlier appointment without any backup documentation provided.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. This individual refused to exit the vehicle during his physical that was scheduled for 1/6. In the future the Residential Director will ensure there is appropriate documentation of any behavioral issues or other issues resulting in non-compliance and/or will cite this on the self assessment. (Supporting Document S34). 04/09/2026 Implemented
6400.144The supplement Molybdenum capsule had a 30-mcg dose on the MAR, but the label on the supplement had a dosage of 250 mcg for individual #2.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The correct dosage is 250mcg. This was corrected on the MAR on 3/23 (Supporting Document S4). 03/23/2026 Implemented
6400.217No release of information documents of any kind were in the file of individual #2.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. This individual's release of information was signed on 4/6/26 (Supporting Document S17). 04/06/2026 Implemented
6400.24The PRN controlled substance medication Lorazepam for individual #2 was in a locked container but was not concurrently in a locked room. Therefore, it was not double locked as required by the 1970 Controlled Substances Act.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The medications were moved to a double locked areas on 3/19 (Supporting Document S5). 03/19/2026 Implemented
6400.32(h)The curtains in the 2nd floor bathroom were see-through. The blinds in the individual's bedroom for both windows were so damaged that they do not provide sufficient privacy coverage from outside.An individual has the right to privacy of person and possessions.The blinds in the bathroom and bedroom were replaced on 4/2/26 (Supporting Documents S29 and S30). 04/02/2026 Implemented
6400.163(g)Medication Ipratropium 0.06% was in with individual #2's medications; however, it was prescribed for staff member #6.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Ipratropium was removed on 3/19/23 (Supporting Document S6). 03/19/2026 Implemented
6400.163(h)The over the counter (OTC) medication Bayer Asprin was in with individual #2's medications; however, it was not on the individual's MAR. The over the counter (OTC) medication Zyrtec was in with individual #2's medications; however, it was not on the MAR, and it expired in 01/2025. The over the counter (OTC) supplement Cod Liver Oil was in with individual #2's medications; however, it was not on the MAR, and it expired in 08/2023.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.All medications that are not listed on the MAR were removed on 3/19/26 (Supporting Document S6). 03/19/2026 Implemented
6400.166(b)The Mirtazapine 8 PM dosage for individual #2 was signed off on the MAR for 03/19/26 and the medication review was done on 03/19/26 at 11:30 AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This was entered by mistake. The Lead staff retrained on medication administration documentation, in the future the Program Manager will conduct weekly medication audits to ensure proper documentation (Supporting Document S23). 03/31/2026 Implemented
SIN-00266046 Renewal 04/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The home contained unlocked non-prescription medications.Poisonous materials shall be kept locked or made inaccessible to individuals. The Prescription Medications were removed from the unlocked area and locked up on the day of inspection 05/02/2025 Implemented
6400.66The light overlooking the rear porch area was not functional.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light was repaired on 5/8/25 (Supporting Document S2). 05/02/2025 Implemented
6400.67(a)The home had a cabinet missing a knob, and the blinds in the individual's bedroom were broken.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds and cabinet were repaired on 5/2/25 (Supporting Documents S3 and S6). 05/02/2025 Implemented
SIN-00243480 Renewal 04/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)No thermometer in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer was in the first aid kit during inspection however the batteries were dead. Thermometer was replaced on 4/29/24. I 04/29/2024 Implemented
6400.112(c)10/17/23 drill did not list an exit route.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Lead staff in the home was retrained on fire drill exits on 5/1/24. In the future Residential Director will review fire drills monthly to ensure exits are listed (Supporting Document S2) 05/01/2024 Implemented
6400.141(c)(12)Individual 4's annual physical completed on 1/5/24 did not indicate whether the individual has physical limitations or not.The physical examination shall include: Physical limitations of the individual. In the future the Residential Director will review individual¿s annual physicals upon completion to ensure the doctor reviews all necessary information and documents such. All physicals have been reviewed and checked for whether or not the doctor verified whether or not there are physical limitations. All physicals now state whether or not an individual has physical limitations 05/01/2024 Implemented
6400.181(a)Individual 4's assessment was completed on 11/4/23 and the previous assessment was completed on 10/4/22. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Residential Director was retrained on assessment timelines on 4/29/24. In the future Residential Director will ensure all assessments are completed annually. (Supporting Document S3) 05/01/2024 Implemented
6400.24The 1970 Controlled Substances Act requires controlled medications to be double locked. Individual 4's medication not kept locked (key was in the lock and box unlocked). Controlled medication, no double lock.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Medications were placed under double lock on 4/29/24. (Supporting Document S4) 04/29/2024 Implemented
6400.32(r)Individual 4's rights statement did not include section (r).An individual has the right to lock the individual's bedroom door.Section (r) was added to the individual rights statement and signed by individual on 5/1/24. (Supporting Document S5) The rights form has been updated with the requested additions and implemented as of 5/29. All individuals had their rights reviewed again on the new form by 6/10. 05/01/2024 Implemented
6400.32(s)Individual 4's rights statement did not include section (s).An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.Section (S) was added to the individual rights statement and signed by individual on 5/1/24. (Supporting Document S5) 05/01/2024 Implemented
6400.34(a)Individual 4's rights were not provided annually. The last one in the record was completed on 2/13/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.individual rights statement and signed by individual on 5/1/24 (Supporting Document S5). 05/01/2024 Implemented
SIN-00224056 Renewal 04/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The front door light bulb was not operational at the time of inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb was replaced on 5/2 (Supporting Document S4). In the future the Residential Director and Program Manager will ensure they are visiting each home weekly to check for maintenance needs and ensure they are completed in a timely fashion (Supporting Document S1) 05/02/2023 Implemented
SIN-00203947 Renewal 04/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)There was only one sleep drill conducted (March 2022) since May 2021.A fire drill shall be held during sleeping hours at least every 6 months. All Live in lead staff have been retrained on conducting overnight sleep drills at least every 6 months (Supporting Document SF1). 04/27/2022 Implemented
SIN-00186410 Renewal 03/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(a)Individual 1's finances were not adequately accounted. for. Disbursements were made on a blank sheet of paper without counting change. Deposits also were not tracked, unknown how much money the individual has outside of petty cash disbursement hand written on sheet. Cash was short 47.25 in December 2020. The agency did not have a formal ledger that tracks such purchases and deposits.There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. A staff financial Accountability form was developed in April of 2021 (Supporting Document #1). A new fiscal management policy was drafted in May of 2021 (Supporting Document #2). 05/03/2021 Implemented
6400.112(e)3914 Cedar Lane did not have a documented sleep drill every 6 months. January's fire drill form dated 1/5/2021 notated a possible overnight drill on January 21 at 10pm directly on that form, but did not document the exit used, location , meeting area and time it took to evacuate.A fire drill shall be held during sleeping hours at least every 6 months. In the future overnight drills will be conducted at least every 4 months. In the future to allow adequate time for administrative review, all fire drills will preferably be completed by the 15th of each month. The Director of Residential Services is responsible for reviewing fire drills and ensuring a satisfactory and compliant fire drill is completed each month. 05/19/2021 Implemented
6400.113(a)Fire safety training was not completed annually for individual 1, most recent training was completed on 3/24/2020. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Upon starting, the Director of Residential recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. 04/01/2021 Implemented
6400.141(c)(6)Tuberculin test was not read with negative results every two years. Last documented test was read on 12/6/2018 for individual 1. Physician stated it wasn't needed but there was no reason stated and no waiver request was submitted to the department.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. A TB test was actually completed on 3/3 and read on March 4 (Supporting document #14) however, this was not in the file at the time of inspection. 04/01/2021 Implemented
6400.151(a)The physical exam was not completed every two years for staff 1. Staff had a check up on 2/27/2020. Unable to verify a general exam was completed and if the staff is free from communicable diseases. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. A physical for this staff is scheduled to be completed 5/18/21. 04/01/2021 Implemented
6400.181(a)The assessment was not completed annually for individual 1, 11/6/2020 was the currently dated assessment. The assessment prior was completed 8/20/18 Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. To prevent reoccurrence, a tracking grid for program specialist paperwork such as assessments has been developed (Supporting Document 3). The Director of Residential Services is responsible for completing and filing all required Program Specialist paperwork within required time frame. The Executive Director will be responsible for reviewing these grids monthly with the residential director. 04/01/2021 Implemented
6400.181(c)The assessment dated 11/6/2020 for individual 1 did not notate what it was based on.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The assessment form has been revised to include a space for describing the source material for the content of the assessment (Supporting document #7). 03/30/2021 Implemented
6400.34(a)Documentation that Individual rights were reviewed with individual 1 was not completed annually and was not provided at inspection. Rights were not reviewed with the individual during 2020 licensing year. Individual Rights were recently signed on 3/24/2021 after licensing requested the document and are now current.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Upon starting, The Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. 04/01/2021 Implemented
6400.169(d)Record of Medication administration training was not kept for staff 1. Unable to verify the record of the training certification from 10/9/20 to 2/20/2021.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Upon starting, The Director of Residential recognized that Staff 1¿s medication administration training documentation was lacking. Thus, staff was retrained on 2/13/21. 03/31/2021 Implemented
6400.181(f)Documentation that the assessment dated 11/6/2020 for individual 1 was sent to all team members at least 30 days prior to the individual plan meeting was not provided.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.In the future the Director of Residential Services will be responsible for sending the assessment to all team members at least 30 days prior to the start of an ISP meeting. The Executive Director responsible for overseeing the Residential Director. 04/01/2021 Implemented
SIN-00119376 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers posted by the telephones.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers have been posted by both telephones in the house by Chris Garavente, President of Special Friends Foundation. Pictures of the postings will be emailed to Rochelle Galen. Special Friends has no staff at this time. However, upon hire, staff will be advised of the location of the phones and posting of the emergency numbers as a standard part of their training. 08/14/2017 Implemented
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Chris Garavente, President of Special Friends Foundation, has corrected the issue of adding a thermometer to the first aid kit. A thermometer was purchased on August 14th. A copy of the receipt and picture of the thermometer will be emailed to Rochelle Galen. There is no need for a plan to prevent future occurrences as the purchase provides a permanent correction. 08/14/2017 Implemented
6400.111(a)The fire extinguisher in the basement was inoperable.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Chris Garavente, President of Special Friends Foundation, has corrected this issue. The fire extinguisher has been replaced with a new extinguisher on August 14th. The Special Friends Policy and Procedures manual has a provision for periodic inspection of fire extinguishers; this policy will serve as the long term plan. A copy of the receipt for the new extinguisher and a copy of the relevant page from the policy manual will be emailed to Rochelle Galen. 08/14/2017 Implemented