Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274231 Initial review 09/25/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.61The program area did not have a telephone with an outside line at the time of the review.The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.On October 1, 2025, operable non-coin operated phones were installed in each room to be utilized for the program - Clement Hall 112 and 114. These phones are operational to an outside line. These phones are easily accessible to individuals and staff members. Please see attachments 2380.61AttachmentA-D. 10/01/2025 Implemented
2380.62The was no emergency numbers list posted by a phone at the time of the review.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.On October 1, 2025, the Emergency Phone numbers list was posted next to each phone in the program rooms Clement Hall 112 and 114. These numbers are the closese hospital, Police Department, Fire Department, Ambulance, and Poison Control. Please see attachments 2380.62AttachmentA-C. 10/01/2025 Implemented
2380.70(a)The was no first aid area on site in the program area at the time of the review.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.On October 1, 2025, a first aid area was created in a seperate room next to the program rooms. This area contains a partition for privacy, a bed, blanket, pillow, and first aid kit with all the required items and first aid manual. Please see attachments 2380.70AttachmentA-F. 10/01/2025 Implemented
2380.83(a)There was no emergency evacuation procedures for the program area at the time of the review.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.On September 30, 2025 a written evacuation plan was created for Clement Hall, which is where the program will be contained. Please see attachment 2380.83AttachmentA. Evacuation diagrams were placed on the walls next to the door of each program room (Clement Hall 112 and 114), at the end of the hall by the entrance to Clement Hall, in front of the Alternate Emergency Exit, and next to the Main Exit. Please see attachments 2380.83AttachmentB-J. 09/30/2025 Implemented
2380.87(a)The fire alarm could be set off at the time of the review; therefore, it was undetermined to know if the system was operable at the time of the review.There shall be an operable fire alarm system that is audible throughout the building.On October 1, 2025, the fire alarm on Clement Hall was tested and it was audible and operable. Please see attachment CHCFIREALARMTEST10.1.25 for video evidence of this test. 10/01/2025 Implemented
2380.88(a)The current extinguishers on-site are rated ABC and not showing a 2-A rating.There shall be at least one fire extinguisher with a minimum 2-A rating for each floor including the basement.On September 30, 2025, an ABC2A Fire Extinguisher was placed in the program area, which is easly accessible and to staff and individuals. Please see attachment 2380.88AttachmentA. 09/30/2025 Implemented