Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265439 Renewal 04/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned on 2/1/2024 and then again on 2/17/2025.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. How we plan to correct the non-compliance: What happened / Why did it happen: The furnace was last inspected and cleaned on 2/1/2024, and again on 2/17/2025, exceeding the 12-month interval required by § 6400.106. This delay occurred due to the termination of our contracted HVAC provider on January 29, 2025, after an unrelated compliance issue at another location. The search for a replacement HVAC contractor coincided with the peak of the heating season, leading to scheduling delays. What specific change was made to fix the problem: A new licensed and insured HVAC provider was contracted, and the furnace was inspected and cleaned on February 17, 2025, bringing the home back into compliance. All required documentation of the inspection was obtained and placed in the home and central compliance files. Who made the change and when: The Facility Compliance Manager coordinated the new contract and scheduled the inspection, which was completed on February 17, 2025. How was the issue corrected: The inspection was completed, and the documentation includes the technician¿s report, service details, and confirmation that the furnace is functioning safely and efficiently. 05/01/2025 Implemented
SIN-00225487 Renewal 06/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Direct Service Worker #1, date of hire 10/24/22, received initial fire safety training on 11/28/22.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The employee identified is no longer employed with the agency. The orientation curriculum in Relias has been updated to include general fire safety. All current employees have completed the required general fire safety, evaluation procedures and responsibilities. 07/21/2023 Implemented
6400.46(c)Direct Service Worker #1, date of hire 10/24/22, received initial first aid training on 12/19/22.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Direct Service Worker # 1 is no longer employed with the agency. All current employees have received their initial first aid training. The Relias cirriculum has been updated to include initial first aid training. 07/21/2023 Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed on 05/03/23, and then again on 05/16/23. Neither appointment form included the name or dosage of the medication listed. It was recorded as "see attached" with nothing attached to the form.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 psychiatry forms have been sent back to the psychiatrist to complete the missing information. The psychiatrist form has been updated to a new version that makes it more visible for the psychiatrist to see where to document the medications and dosage. 07/28/2023 Implemented
SIN-00208137 Renewal 06/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 6/29/22, at 11:48 AM., the water temperature at the bathroom sink measured 126.3 degrees Fahrenheit.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Provider has turned down water temperature on water heater, water temperature was tested for 1 week straight to ensure water under 120 degrees. * home is currently vacant 08/15/2022 Implemented
SIN-00243996 Renewal 05/01/2024 Compliant - Finalized