Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282115 Renewal 12/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Fire safety training was not provided to Individual 4 upon admission to the Community Living Arrangement (CLA). General fire safety training was completed on 08/29/25. The regulation states that the training must include home specific training in addition to general fire safety. 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. All individuals will receive fire safety training when first move into home and annually thereafter. The individuals will received a certificate once completed and will be in the individuals records. Site specific fire safety for individuals 4 will be conducted by Wednesday March 11, 2026 for violation 6400.113(a). 01/05/2026 Implemented
6400.141(a)The 08/21/25 annual physical exam for Individual 4 does not include several elements of part c of the regulation.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. We will ensure that all annual physical examinations include all required components outlined in C 6400.141. Physical exam documentation will be reviewed to confirm completeness prior to filing in the individuals record 01/05/2026 Implemented
6400.24The 07/14/2025 criminal background check for Staff 8 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.W of thre have implement a written policy requiring a case-by-case review of any applicant with criminal background, in accordance with 6400 regulations and state requirement. The review will consider the nature and the severity of the the offense, the date of the offense, relevance to the position evidence of rehabilitation and any prohibitive offenses identified under regulation. All hiring decisions and supporting rationale will be documented and approved by management 01/06/2026 Implemented
6400.34(a)Individual 4 was not informed of their rights as outlined in §6400.32.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.All individuals will review and sign their Individual Right annually ay the beginning of each calendar year 01/05/2026 Implemented
6400.52(c)(6)There was no record on file to show that Staff 9 was trained in the Implementation of the individual plan of the person they work directly with.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All staff will complete their required annual training . The Program Specialist will oversee and ensure compliance with training requirments including tracking completion and maintaining documentation 01/06/2026 Implemented
6400.165(g)Psychiatric medications for Individual 4 were reviewed on 08/21/25 by a physician, but no psychiatric medication review has been done since then.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The company will ensure that any medication prescribed to treat psychiatric symptoms is reviewed by a licensed physician at least 3 month. The physician review will include documented confirmation of The clinical reason for the prescribing the medication The continued need for medication The appropriateness and effectiveness of current dosage All reviews will be maintained in individual medical record to ensure regulatory compliance 01/06/2026 Implemented
6400.181(f)Individual 4's annual assessment was not provided to the ISP team at least 30 days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist will schedule and conduct the team meeting at least 30 days prior to the individual ISP meeting to review the individuals progress, needs and any recommended updates. Documentation of the meeting, including attendees and discussion summary, will be maintained in the individuals record 01/06/2026 Implemented
6400.183(c)The list of people who participated in the individual plan meeting on 11/04/25 for Individual 4 was not in the record.The list of persons who participated in the individual plan meeting shall be kept.Moving forward the company will ensure that all participants attending an ISP meeting sign an attendance sheet at the time of the meeting. The attendance record will include name, title/ relationshio, and date of the meeting. Documentation will be maintained in the individual record 01/05/2026 Implemented
6400.213(1)(i)Individual 4's record did not include information about their hair color, color of eyes and identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The provider will ensure that all required personal information is fully completed in each individuals record, including hair color, eye color, identifying marks, full name, sex, admission date, date of birth, and social security number. All current records will be reviewed to confirm completeness, and any missing information will be obtained and documented promptly. 01/05/2026 Implemented
SIN-00259076 Renewal 01/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There is no antiseptic 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. House manager will be responsible for correcting the problem in the future. House manager will check first aid kits monthly to ensure all items are available. If any items are missing house manager will replace with in 24 hours. 01/31/2025 Implemented
SIN-00238877 Renewal 01/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom had antibacterial hand soap.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The above mentioned bathroom had soap in and unlabeled dispenser. The hand soap refill bottle was located under the bathroom sink. It was shown at time of inspection. All soap bottles/dispensers will have labels on them showing the name and contents. 01/31/2024 Implemented
6400.112(c)The exit route was not indicated on the form.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. All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. 02/05/2024 Implemented
6400.112(c)On 9/16/23, the form did not indicate if alarms were operable.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. All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. 02/05/2024 Implemented
6400.112(d)On 12/18/23 and 11/2023, fire drill was over 3 1/2 minutes, no other fire drill was conducted, or problem identified to show why the fire drill went over 2 1/2 minutes. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. All direct support staff will be retrained on fire drill evacuation times. No consumer fire drill should exceed 2.5 minutes or within the period of time specified in writing within the past year by a fire safety expert. Direct support will report any fire-drills that lasts over 2.5 minutes directly to management immediately. 02/05/2024 Implemented
6400.112(i)On 7/3/23, the fire drill form did not indicate what alarm was used. A fire alarm or smoke detector shall be set off during each fire drill.All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. 02/05/2024 Implemented