Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293437 Renewal 08/17/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for this 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.Tranquil Hearts determined that the required Chapter 6400 self-assessment had not been completed within the applicable timeframe because an incorrect self-assessment form had been used. Following the licensing inspection, Tranquil Hearts obtained and completed the correct Chapter 6400 Community Homes Self-Assessment Tool for the home. Any areas identified during the self-assessment requiring correction were addressed accordingly. We also reviewed the self-assessment requirements for its other Chapter 6400 homes to verify that the correct form is being used and that future self-assessments are completed within the required timeframe. 09/28/2026 Implemented
6400.112(f)The 5/22/26 fire drill paperwork does not identify the exit route that was used.Alternate exit routes shall be used during fire drills. Tranquil Hearts reviewed the fire drill record dated 5/22/2026 and determined that the exit route used during the drill had not been documented on the fire drill paperwork. The omission was a documentation error specific to that drill. The home's usable evacuation route is through the front entrance/exit. The rear sliding door opens to a balcony and is not used as an evacuation route. Staff were reminded that the actual exit route used during each fire drill must be clearly documented on the fire drill record. We also reviewed recent fire drill documentation for the home to verify that evacuation routes were being recorded and addressed any incomplete documentation identified. 08/26/2026 Implemented
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