Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278656 Renewal 11/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Individual #2's Service Plan, last updated 8/28/25, states that "With prompts, [Individual #1---date-of-birth: 7/26/90] can safely evacuate the area in less than 2.5 minutes during a fire drill." However, the home's Fire Department Notification Letter, dated 8/29/25, did not indicate the exact location of Individual #2's bedroom, as it read: "All bedrooms are on second floor. One elderly male [not in reference to Individual #2] in front bedroom is a fall risk and has impaired memory." In addition, this home's Fire Department Notification Letter, dated 8/29/25, did not include a description or diagram of the home's general layout in relation to the individuals' bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. On 11/19/2025, evacuation needs and floor plans were sent in writing to the appropriate Fire Departments for all Twin Trees, Inc. sites. Notification included the exact location of the bedrooms of individuals who need assistance evacuating in the event of a fire. 11/19/2025 Implemented
6400.141(c)(11)Individual #1's current physical examination, completed on 7/2/25, did not include an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals, as the corresponding field was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. On 11/18/2025, Program Director and CEO developed a new internal protocol on reviewing all individual's physical examinations. On 11/19/2025, Program Director trained Program Specialists and Agency Nurse on the change in internal protocol for review of all individual's physical examination forms to make sure they are completed in entirety. 11/19/2025 Implemented
SIN-00202230 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill conducted on 6/16/21 did not indicate the exit route used.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. The site-coordinator who is trained in general fire safety, evacuation procedures, responsibility during a fire drill, designated meeting place, smoking safety, use of a fire extinguisher, and notification procedures will retrain the house staff at a mandatory fire safety training. This training will stress the importance of completing the fire drill form accurately and completely to ensure all required information is captured when a fire drill is completed. The following information will be included on all fire drills: Date-the month, day and year in which the fire drill was completed Time- the time of day, including the designation of AM/PM or 24-hour format The amount of time it took for the evacuation- timed from the time the alarm was set off till all occupants came out the exit The exit route used- all exit routes used except the route that is blocked by the simulated fire Problems encountered-this can include individuals who refused to evacuate, a staff person who failed to accurately perform his/her duties, or any other events that impacted the evacuation. Problems should be in detail, as awareness of problems will allow the home to remedy them. Weather the fire alarm or smoke detector was operative. 03/30/2022 Implemented
SIN-00106199 Renewal 12/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)Individual #1 is being monitored by an audio monitor located on a wall shelf in the hallway near the bathroom on the second floor of the home. The receiver of the monitor is in the living room on the first floor of the home.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The audio monitor has been removed and is no longer in use. [Immediately, a designated staff person shall check all homes to ensure privacy in bedrooms, bathrooms and during personal care is maintained and the use of audio monitors is not being used. Within 30 days of receipt of the plan of correction, all staff person shall be educated on the individuals' rights including the right to privacy in bedrooms, bathrooms and during personal care. (AS 1/26/17)] 01/17/2017 Implemented
SIN-00071295 Renewal 10/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)Three of the floor boards located under the covered deck in the back of the home are displaced approximately two inches which poses a tripping hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The gazebo and rotted wood was removed on 10-7-14 by Mark Livingston and replaced with decorative stone. [The program specialist or designee with audit all home's exterior conditions to ensure the yard is well maintained, in good repair and free from unsafe conditions monthly. (CHG 12/8/14)] 12/01/2014 Implemented
SIN-00260226 Renewal 02/05/2025 Compliant - Finalized
SIN-00239418 Renewal 02/14/2024 Compliant - Finalized
SIN-00219431 Renewal 02/13/2023 Compliant - Finalized
SIN-00183869 Renewal 02/25/2021 Compliant - Finalized
SIN-00166684 Renewal 11/25/2019 Compliant - Finalized
SIN-00126301 Renewal 12/18/2017 Compliant - Finalized
SIN-00077941 Renewal 12/09/2015 Compliant - Finalized
SIN-00049604 Renewal 08/23/2013 Compliant - Finalized