Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283525 Renewal 01/15/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.69(e)At the time of inspection there was no hand soap in the bathrooms at the facility.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.Director will ensure all bathrooms contain soap with their original label daily. 01/20/2026 Implemented
2380.111(c)(3)There was no documentation to illustrate that Individual #1 had a current Tdap as required. Documentation provided indicated that the last Tdap was completed on 10/26/15.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Director was unaware of the provider's responsibility to ensure all individual's Tdap immunization is up to date/current. 01/20/2026 Implemented
2380.111(c)(4)The physical for Individual #1 dated 8/15/25 did not provide results of vision and hearing screenings. The section assigned for the information was blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Director will continue to examine all physical forms upon receipt and follow up with all individual's caregivers/medical providers to ensure the physical form is completed in its entirety. 01/20/2026 Implemented
2380.111(c)(10)The physical for Individual #1 dated 8/15/25 does not record medical information pertinent to diagnosis and treatment in case of an emergency. The section assigned for the information was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Director will ensure the individuals health records contain instructions to be followed for an individual's treatment, in case of emergency, as it pertains to their health diagnosis. 01/20/2026 Implemented
2380.113(c)(2)Staff #1 was hired on 9/29/25. The physical for Staff#1 was completed on 9/29/25 with documentation of the tuberculin skin test being completed on 7/17/24. The tuberculin skin test was greater than one year prior to their hire date as required.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Director has requested an updated Tuberculin skin test for Staff #1. 01/20/2026 Implemented
2380.173(1)(ii)The records of Individual #1 and Individual #2 both noted identifying marks as "N/A." Identifying marks are applicable to all and required information for each individual. Identifying marks allow for immediate access of crucial information in the event that an individual is missing or experiences a medical or behavioral emergency requiring immediate treatment.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Director will ensure that all individual's face sheet contain some type of identifying mark. 01/21/2026 Implemented
2380.181(e)(13)(i)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of health. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The Director will ensure the each individual's assessment will contain their progress in the area of health over the last 365 calendar days. 01/21/2026 Implemented
2380.181(e)(13)(ii)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of motor and communication skills. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Director will ensure the each individual's assessment will contain their progress in the areas of motor and communication skills, over the last 365 calendar days. 01/21/2026 Implemented
2380.181(e)(13)(iii)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of personal adjustment. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Director will ensure the each individual's assessment will contain their progress in the area of personal adjustment over the last 365 calendar days. 01/21/2026 Implemented
2380.181(e)(13)(iv)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of socialization. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Director will ensure each individual's assessment contain their progress in the area of socialization over the last 365 calendar days. 01/21/2026 Implemented
2380.181(e)(13)(v)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of recreation. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Director will ensure each individual's assessment contain their progress in the area of recreation over the last 365 calendar days. 01/21/2026 Implemented
2380.181(e)(13)(vi)The assessment for Individual #2 dated 9/6/25 did not include their progress over the last 365 calendar days in the area of community integration. The section contained the same information as the assessment completed on 8/3/24.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Director will ensure each individual's assessment contains their progress in the area of community integration, over the last 365 calendar days. 01/21/2026 Implemented
2380.37(a)Various training records for Staff #1, #2 and #3 did not include the required information of training source and training hours earned for each training course provided. Training was completed but lacked the required details of training source and length of the training.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Director will ensure the all training records includes the training source, and length of training. 01/20/2026 Implemented
2380.39(b)(1)Documentation of training for the CEO, Staff#2, illustrated a total of 4.5 hours completed for the 2025 training year. Documentation did not support the completion of 12 hours as required.The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Director has merged the two training record systems to ensure that all training records are maintained within one electronic data systems, to mimize misplacement of training records. 01/22/2026 Implemented
SIN-00266282 Initial review 05/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.69(e)The bathroom on the upper floor of the building lacked a wall mirror at the time of inspection.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.A wall mirror has been installed in the bathroom on the upper floor of the building. 05/20/2025 Implemented
2380.70(b)At the time of inspection, the program's first aid area lacked a bed or cot, a blanket, and a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.A cot, blanket and pillow has been placed in the first aid area. 05/20/2025 Implemented