Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00284571 Renewal 02/04/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)On 2/4/2026 at 11:03AM, there were three plastic, unlabeled spray bottles with unknown substances on a shelf in the basement of the home.Poisonous materials shall be stored in their original, labeled containers. On 2/4/26, all unlabeled bottles were immediately removed from the basement by the CEO to eliminate any potential safety risk. At the time of the inspection, the presence of unlabeled substances was due to a lack of staff training and oversight regarding proper storage and labeling requirements for hazardous materials. 02/04/2026 Implemented
6400.68(b)On 2/4/2026 at 10:51AM, the hot water temperature measured 122.3F at the bathtub in the bathroom on the first floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 2/4/26, the temperature setting on the hot water tank was adjusted to ensure compliance with required temperature limits. On 2/5/26, water temperatures were tested three times and verified to be below 120°F. At the time of the inspection, water temperature readings were within compliance but were recorded close to the maximum allowable limit. This identified a need for improved monitoring and clearer internal temperature standards to prevent exceeding the limit. 02/05/2026 Implemented
6400.72(b)On 2/4/2026 at 10:54AM, there was a one-inch by one-inch hole in the screen in the only window in the vacant bedroom. Screens, windows and doors shall be in good repair. On 2/5/26 the screen was repaired by a Safe Haven maintenance person. This was arranged by the Program Specialist and administration of Safe Haven Group Home llc. The repair was not completed at the time the damage occurred because the damage was not reported by staff in a timely manner. This identified a gap in staff training and reporting procedures. 02/05/2026 Implemented
6400.113(a)Individual #1, date of admission 11/15/2025, was initially instructed on general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe, and smoking safety procedures on 11/16/2025. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. On 3/10/26 The admission checklist was updated by the CEO to include documents needed on / before admission. Individual #1 did not complete required fire safety training upon admission due to an incorrect understanding of regulatory requirements. This identified a gap in the admission process and staff training for PS and administrative team. 03/10/2026 Implemented
6400.141(c)(1)Individual #1's physical examination, completed 9/12/2025, did not include a review of the individual's previous medical history. This section was omitted entirely from the physical examination form.The physical examination shall include: A review of previous medical history. On 2/5/26, the previous medical history for Individual #1 was added to the physical examination form to ensure the form was complete. At the time of the inspection, the physical form was incomplete due to a gap in staff understanding of documentation requirements. 02/05/2026 Implemented
6400.171On 2/4/2026 at 10:48AM, there were two cartons of eggs with best by dates of 11/21/2025 and 12/24/2025 on the shelf in the refrigerator in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. On 2/4/26, the expired eggs were immediately discarded by the CEO to eliminate any potential food safety risk. At the time of the inspection, expired food items were present due to a lack of consistent monitoring and food rotation practices. 02/04/2026 Implemented
6400.181(c)Individual #1's assessment, completed 1/15/2026, stated the following under the individual's water and swimming safety assessment, "[Individual #1] is able to swim but does not go swimming according to [their] ISP. According to [their] ISP, [they] will need full supervision while swimming in a large body of water." This section of Individual #1's assessment was based on information in the individual support plan rather than assessment instruments, interviews, progress notes, and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations. On 2/10/26, the initial assessment for the individual was revised by the administration team to accurately reflect that the information was obtained through interviews and meetings with the individual's team, rather than from the Individual Support Plan (ISP). At the time of the inspection, the assessment incorrectly referenced the ISP as the source of information, which identified a need for clarification of assessment requirements and proper documentation practices. 02/10/2026 Implemented
6400.181(e)(4)Individual #1's assessment, completed 1/15/2026, did not include an assessment of the individual's need for supervision in the residential home or community. The assessment must include the following information: The individual's need for supervision. On 2/10/26, the assessment for Individual #1 was revised by the CEO to include the need for supervision in both the home and community. The revision was completed by the CEO/administrative team. At the time of the inspection, this information had not been included in the assessment due to an administrative oversight and lack of clarity regarding documentation requirements. This identified a need for additional training for the administrative team. 02/10/2026 Implemented
SIN-00261827 Renewal 02/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 2/11/2025, at 1:39pm, the Microwave was observed with food splatters on inner ceiling and walls.Clean and sanitary conditions shall be maintained in the home. The microwave was immediately cleaned out by DSP to remain complaint. [A blank "microwave sign off sheet" was received on 5/20/2025 and reviewed 5/29/25. DPOC by HSKP, HSLS, on 5/29/25.] 02/11/2025 Implemented
6400.68(a)On 2/11/2025, the water temperature measured 80.4 degrees Fahrenheit in full bathroom tub at 1:42pm and 80.2 degrees Fahrenheit at 1:43pm at the sink.A home shall have hot and cold running water under pressure. The Program Specialist adjusted the water heater settings Immediately to increase the temperature until it reached 115°F, ensuring that the water temperature is within the appropriate range for safe and comfortable use. This is compliant with the regulation for chapter 6400.68 (a). [Blank weekly water temperature log was received on 5/20/25 and reviewed 5/29/25. A blank home inspection list that includes water temperatures was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 02/11/2025 Implemented
6400.81(h)On 2/11/2025, The two windows in Individual #1's bedroom were covered with a film that does not permit a view to the outside.Each bedroom shall have at least one exterior window that permits a view of the outside. The plastic film cover was removed immediately by PS from the windows of individual's #1 restoring an exterior view. [A blank "Home Inspection Checklist" that include windows with exterior views was received on 5/20/25 and reviewed 5/29/25. Training documentation, dated 2/14/25, that addressed that at least one bedroom window must permit a view of the outside, was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 02/11/2025 Implemented
6400.101On 2/11/2025, there was a bar on the sliding door in the dining room that would obstruct egress in the event of an emergency. There was a key operated lock on the inside of the garage door and the garage door does not have another point of egress, therefore presenting an entrapment risk. There was a sliding lock on exterior side of storage room at the bottom of the basement steps presenting an entrapment risk. There was a turn/thumbnail lock on the kitchen door that leads to the basement turn lock on kitchen side and no other means egress from the basement presenting an entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 2/11/25 The bar was removed immediately from the slide to door to prevent entrapment in case of an emergency. On 2/15/25 - sliding lock on exterior side of storage room door was removed On 2/15/25 ¿ Key-operated lock on the door to the garage was removed and replaced with a regular doorknob. On 2/15/25 ¿ Thumbnail lock on the kitchen door turned around so the turn lock is now on the basement side, ensuring egress from the basement. [A blank "Home Inspection Checklist" that includes unobstructed egress was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 02/15/2025 Implemented
6400.112(c)The garage door was used as an exit during fire drills conducted on 6/15/2024, 10/8/2024, and 11/21/2024. This is not defined as an egress by the Uniform Construction Code.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. On 2/15/25, all management teams reviewed and were trained on site violations to include not being able to use a garage door as a means of egress for a fire evacuation. In addition, a sign was posted by the garage door to indicate that the garage should not be used as a means of egress for a fire safety evacuation drill. [Training documentation, dated 2/14/25, that addressed garage door are not egress point for emergency evacuation purposes was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 02/15/2025 Implemented
6400.141(c)(7)Individual #1, date of admission 4/15/2024, has not had a gynecological examination completed since admission. According to testimony from agency staff, the individual has refused this form of treatment; however, no documentation of refusals or ongoing training was completed.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual #1 is scheduled for an annual gynecological exam on 4/8/25. On 3/14/25, The owner revised the individual's Physical Health Assessment to be more specific in the area of a gynecological exam. If no exam has been given, the doctor is now requested to give a deferred date for the exam and / or check a box for a refusal. [A blank "Home Inspection Checklist" that includes individual physical examinations, including gynecological examinations, was received on 5/20/25 and reviewed 5/29/25. Training documentation, dated 2/14/25, that addressed that gynecological examinations are "logged", was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 03/14/2025 Implemented
6400.182(c)Individual #1's annual assessment was completed on 6/10/2024 and sent to the plan team on 1/15/2025 for an Individual Support Plan (ISP) meeting scheduled for 3/4/2025. The assessment was not updated or reviewed within 6 months prior to the ISP meeting to ensure the information provided to the team was accurate and current.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The most current/ updated assessment was completed and sent to her SC on 1/15/25. However, the date was not changed to indicate the update. The date was changed immediately from 6/10/24 to 1/15/25 on 2/12/25 to indicate the correct update date and no changes in the assessment. [A copy of the Delegation Chart was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 02/12/2025 Implemented