Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292295 Renewal 07/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff member 1's physical is dated 07/02/2026, was hired 01/07/2026. Staff member 2's physical exam is dated 07/01/2026, after their date of hire 02/23/2026. Staff member 3's physical exam is dated 07/07/2026, date of hire was 02/23/2026. Staff member 4 does not have a staff physical on file.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Physical forms for all staff that have been hired to date have been completed and placed in the staff records file. Each staff member has completed a physical and those documents are maintained in the master Staff Records binder. The Executive Director has ensured that these forms have been completed. 07/30/2026 Implemented
2380.181(a)Individuals 1 and 2's initial assessments were not completed timely (within 60 days of their respective admission dates).Each individual 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.An assessment form has been created for use in compliance with Regulation 2380.181 and all subsections. This form has been placed in the individual record and these assesments will be updated annually moving forward. In addition, any new admission to the program will have an initial assessment done in compliance with 2380.181 and all sub-sections, and that assessment will be shared with each individual's respective Supports Coordinator, placed in their individual record, and updated in an annual basis. 07/30/2026 Implemented
2380.21(u)Individual rights statements are all dated 06/30/2026, after all the individuals' admission datesThe facility 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 facility and annually thereafter.All individual rights statements have been completed and placed in the individual record. The Rights policy and process to report a Rights violation have been provided to the individual, as well as their families/caregivers These forms will be reviewed with the individuals on an annual basis. 07/30/2026 Implemented
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