Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274156 Renewal 09/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)REPEAT 12/16/24-Individual #1's annual assessment was not complete. The assessment in the record was not signed and dated by the PS and did not contain all of the assessment regulations. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Tranquil Hearts has completed a new, comprehensive annual assessment for Individual #1, ensuring all required regulatory components under 6400.181(a)--(f) are included. The updated assessment now contains all mandatory sections such as adaptive behavior, level of skills, communication, socialization, mobility, personal needs, medical information, and interests. The assessment has been reviewed, signed, and dated by the Program Specialist and placed in the individual's record. Copies have been distributed to the team, including the Supports Coordinator and family, as required. The Program Specialist has received additional training on the completion, content, and timeliness of annual assessments to prevent reoccurrence. 10/10/2025 Implemented
SIN-00256858 Renewal 12/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. December 17,2024- The self-assessment was not completed in the correct amount of time which is 3 to 6 months prior to the expiration date of our compliance. We have put on all calendars (electronic and physical) to submit self-inspection in the correct time. 12/22/2024 Implemented
6400.64(a)At the time of the inspection on 12/18/24, there was a jar of mayonnaise that expired on 12/3/24 in the refrigerator of the home.Clean and sanitary conditions shall be maintained in the home. The jar of mayonnaise was immediately discarded 12/20/2024 Implemented
6400.68(b)At the time of the inspection on 12/18/24, the water temperature was 127.9 degrees in the bathroom next to the unoccupied bedroom, 124.7 degrees in the bathroom next to the occupied bedroom, and 123 degrees in the kitchen sink. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was turned on 12/18/24.The new reading ranges from 103 t0 106. 12/18/2024 Implemented
6400.145(1)The medical plan for Individual #1 did not have the hospital or source of health care that will be used in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. December 19, 2024- An updated emergency medical plan is now in place for Individual #1 which asks their preferred hospital and states the nearest hospital and in case of emergency and preferred hospital is not available is the nearest okay to be used. 12/19/2024 Implemented