Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288339 Renewal 05/26/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Staff # 5 had fire safety training on 4/28/25 and not again until 4/30/26, outside of the annual timeframe. Staff #3 had FS training on 4/28/25 and not again until 5/19/26, outside of the annual timeframe. Staff #2 had FS training on 1/24/25 and not again until 2/6/26, outside of the annual timeframe. Staff #6 had FS training on 1/28/25 and not again until 3/9/26, outside of the annual timeframe.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The staff members listed above have already completed the required fire safety training, although it was not completed within the required timeframe. The 2026 training completion date (month/day) for each staff member will be used as their annual training date for determining when the next fire safety training is due. 06/22/2026 Implemented
SIN-00272006 Renewal 09/02/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Staff #3's annual physical, dated 7/28/25, does not indicate whether or not they are free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #3 had their physical on 7/28/25. A Mantoux skin TB test was placed on that date. Usually, the health provider conducting the physical will not sign off that the staff member is free of communicable disease unless the TB test is read. On 7/31/25, when Staff #3's TB test was read, the health provider forgot to check the box indicating that they were free of communicable disease. An updated physical form confirming that Staff #3 is free of communicable disease was obtained from the provider (9/13/25) and is currently on file (Attachment #2). The CEO has reviewed the records of all other staff members and ensured that their physicals are in compliance (9/12/25). 09/13/2025 Implemented
6400.166(b)At the time of the inspection on 9/3/25, the medication log was not initialed for the administration of Quetiapine Fumarate 50mg @ 10pm on 9/2/25. The medication was confirmed as administered via the blister package.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The medication was confirmed as administered via the blister package on 9/3/25. According to the staff who administered the medication, they were unable to sign at the time of administration due to issues with the Therap system (the agency recently transitioned from paper MARs to an electronic system Therap). An inspection by the CEO on 9/13/25 confirmed that the administration has since been documented (Attachment #3). 09/13/2025 Implemented