Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274411 Renewal 09/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash receptacles found outside of the home did not have lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The outdoor trash bin lids were damaged during recent trash collection and were not immediately replaced. Staff failed to report the damage to the Program Manager for follow-up. Corrective Action Taken: New trash bin lids were purchased and installed on 9/19/2025. The Program Manager verified that all outdoor receptacles are now equipped with secure, functional lids. Photos were taken as documentation of correction. 09/19/2025 Implemented
6400.66There was no lighting for the back exit of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The back exit area did not have an exterior light fixture installed. A new exterior light fixture was installed on 9/19/2025 to ensure the back exit is properly illuminated and safe for use during nighttime hours. The Program Manager took photo and verified that the light is fully functional. 09/19/2025 Implemented
6400.67(a)There were two missing knobs on the stove.Floors, walls, ceilings and other surfaces shall be in good repair. The stove knobs had been removed for cleaning and were misplaced. The missing parts were not reported to the Program Manager for replacement prior to inspection. Plan of correction: Replacement stove knobs were purchased and installed on 9/19/2025. The stove was tested to ensure it is in safe and proper working condition. The Program Manager took photos, verified completion of the repair and documented the correction. 09/19/2025 Implemented
6400.72(b)There were holes in the bedroom door of the back room which is used as an office. Screens, windows and doors shall be in good repair. The door was damaged by an individual during a behavioral crisis. Although the damage was reported, the repair was delayed due to pending material replacement. The door was repaired on 9/22/2025, and the Program manager verified that it is now in good condition and free from holes, photos were taken and documented completion of the repair. 09/22/2025 Implemented
6400.144The medication Lovaza 1GM Capsule was found on the MAR but not available during inspection for Individual #1. Ondansetron 4MG Tablet is listed on the MAR twice as a PRN but was not found during inspection.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. Both medications were in the home's locked medication storage box at the time of inspection. Staff verified that the medications were present and matched the active prescriptions. Plan of correction: Following the inspection, the Program Manager and RN confirmed that both Lovaza 1GM Capsules and Ondansetron 4MG Tablets were in the medication box, properly labeled, and stored according to ODP medication administration requirements. Program Manager took photos were taken and submitted for documentation. 09/18/2025 Implemented
SIN-00272870 Unannounced Monitoring 08/26/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(e)During the Departments inspection on 8/26/2025 interview, Individual #3 is not allowed to use the deck area at the back of the home unless Individual #3 requests permission to use the area.An individual has the right to make choices and accept risks.The locks were replaced on the door leading to the deck and now the individual can lock and unlock the door to the deck and use the deck at her free will. 09/03/2025 Not Accepted
6400.32(h)The staff #1 was greeted by individual #3 and their conversation began with cursing as if it was the norm and terms of endearment. Licensing then asked individual #3 if we could interview them and individual #3 responded "yes". Before licensing could proceed with the interview, the staff #1 was guiding individual #1 on how they should answer what staff #1's thought the interview questions would involve. Licensing then asked staff #1 to leave the room so that individual #3 could be interviewed without disruption.An individual has the right to privacy of person and possessions.When individuals are being interviewed by an outside source staff will ask the individual if they would like them to stay or if they would like them to step out of the room. Staff will allow the individual to speak for themselves at all times. 09/03/2025 Not Accepted
6400.45(e)Individual #3 is to have 2:1 staffing from 8am-8pm, on 8/26/2025 at 10am, , during the Department's inspection of the home, only one staff member was present.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.The Program Manager has retrained staff on the importance of maintaining the supervision guidelines at all times as a break in these supervision guidelines is a health and safety risk to the individual. 09/03/2025 Not Accepted
6400.186Individual #3's ISP states they are to have 2:1 staffing from 8am-8pm. On 8/26/2025 at 10am, during the Department's inspection of the home, only one staff member was present.The home shall implement the individual plan, including revisions.The Program Manager has retrained staff on the importance of maintaining the supervision guidelines at all times as a break in these supervision guidelines is a health and safety risk to the individual. If at any time the supervision guidelines are broken the staff should immediately contact the program Manager. 09/03/2025 Not Accepted
SIN-00255556 Renewal 11/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)Soiled bug traps were found in the office.There may not be evidence of infestation of insects or rodents in the home. The program manager will remove the soiled bug traps immediately and replace them with clean, appropriate pest control devices. The Program Manager will verify that the area has been cleaned and sanitized following the removal of the traps. All soiled bug traps in the office will be removed and replaced to maintain a clean and sanitary environment. November 6: The program manager will remove the soiled traps and sanitize the affected areas. November 7: New traps will be installed as necessary, and all pest control devices will be placed in inconspicuous, sanitary locations. A full inspection of the site will be conducted to identify and address any additional sanitation issues. The Program Manager will ensure that a pest control log is implemented to monitor and manage the use of traps and other pest control measures. 11/07/2024 Implemented
6400.112(c)For the 08/20/24 fire drill record the time of day was entered where the evacuation time minutes should have been entered.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 Program Specialist will correct the 8/20/24 fire drill record by entering the actual evacuation time in minutes, as verified by staff involved in the drill. The Program Manager will review and approve the correction to ensure accuracy. The 8/20/24 fire drill record will be updated with the correct evacuation time in minutes. The Program Specialist will contact staff present during the 8/20/24 drill to confirm the actual evacuation time. The corrected evacuation time will be recorded on the fire drill form, with the correction signed and dated by the Program Specialist. All fire drill records from the past 12 months will be reviewed by the Program Specialist to ensure accuracy and compliance. Any errors will be corrected by December 1, 2024. The Program Manager will ensure that all fire drill records moving forward are reviewed for accuracy before being finalized and filed. 11/07/2024 Implemented
6400.166(b)There is no documentation or initialing on the MAR that all prescribed medications for 8 AM were administered despite the medications being administered to Individual 2 at 8am on 11/6/2024.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Nurse will review the MAR for November 16, 2024, and verify the administration of the 8 a.m. medications for Individual 2. The DSP responsible for the error will complete retraining on medication documentation policies. The MAR will be updated to accurately reflect the administration of Individual 2¿s 8 a.m. medications on November 7, 2024. The DSP will initial the MAR to indicate the medications were administered as required. November 7, 2024: The Nurse will review and update the MAR for compliance. November 25, 2024: The DSP will receive retraining on Chapter 6400 medication documentation requirements and the importance of completing the MAR promptly and accurately. A full review of all MARs for the current month will be conducted to identify any other instances of missing documentation. Any discrepancies will be corrected immediately, and all staff responsible will be retrained. 11/07/2024 Implemented