Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264911 Renewal 04/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 2/25/25 did not have an evacuation time listed.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. 04/25/2025 ¿ The fire drill policy and procedure was updated and revised to ensure that all the regulatory measures are met in full. This includes ensuring that key components of the record are present such as the time in minutes and seconds of completion, exit route utilized upon exiting the residence, time of day, date completed, as well as the signature of the completing staff members. A new form was created as well which clearly defines minutes and seconds in the following format [ Duration of Drill: ___ minutes ___ Seconds]. Previous reporting included decimals in seconds, which created a lot of confusion in regards to the accurate duration of the drill carried out. Finally, a monthly checklist for each residence was created to effectively track fire drills, including a question of ¿did the individual(s) evacuate in the required time 2 ½ minutes (unless otherwise defined by a fire Marshall). Additional update to policy includes standards and expectations for repeating drills that are not compliant within the same month (e.g. March fire drill completed in 2 minutes and 50 seconds, this drill will be completed again within the same week, and repeated until compliance is met). 04/25/2025 Implemented