Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279151 Renewal 11/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)On 11/25/2025 at 10:23AM, there was no cover on the drain on the floor in the basement of the home posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Valley Maintenance department put brand new drain cover in the basement. Photo Proof in attachments 11/25/2025 Implemented
6400.70On 11/25/2025 at 10:15AM, the telephone service in the home was not operable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Immediate POC 6411.70 Valley Advantages began implementing Ooma AirDial as a direct substitute for current analog phone lines at all residential locations. Road Ooma box installed and operating effectively 12/15/2025 12/15/2025 Implemented
6400.104The provider agency sent a fire notification letter to the local fire department on 8/27/2025, indicating one individual resides in the home. There are currently two individuals residing in the home.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. Update Notification to Limestone fire hall for road location and send letter and floor plan to closest fire department Showing change in individuals 12/16/2025 Implemented
6400.165(b)Individual #1 was prescribed Chlorhexidine Glucose Solution 0.12% with instructions to, "swish and spit 15ML by mouth twice daily for dental health." This prescription was discontinued on 11/20/2025 and the medication instructions were changed to "Swish and spit 15ML by mouth after each meal at bedtime as needed for dental health." The discontinued medication was administered to Individual #1 twice daily, following the original instructions until 11/24/2025 at 8AM.A prescription order shall be kept current.6400.165(b) Immediate POC: : Valley Advantages, RN, changed medication in the electronic health record to match the prescription label on 11/25/2025, to maintain compliance and to assure the health and safety of individual #1. 11/25/2025 Implemented
6400.165(g)A review of Individual #1's psychotropic medications was completed on 7/10/2025 and then again on 10/16/2025.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Immediate POC 6400.165(g) individual #1 did have his psychotropic medication review completed, it was 6 days late, Individual did not show signs of the delay affecting his mood stability, but valley advantages were not compliant with 6400.165(g) His quarterly medication review was scheduled within the regulatory standards. Individual #1s appointments are being inputted into Electronic Health Records, 1/1/2026 a reminder notification will be added to this platform. 12/19/2025 Implemented
SIN-00256784 Renewal 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)On 12/4/24, at 12:08 PM, there was no well-secured handrail on the interior wooden stairs leading to the attic of the home. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 12/4/24, a secured handrail was installed on the interior steps at the service location. A picture was taken of the completed task and submitted to the licensing agent. 12/04/2024 Implemented
6400.107On 12/4/24, at 12:01 PM, a portable space heater was located on a shelf in the staff office closet.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. Upon discovering a violation of 6400.107, the Residential Manager removed the Space Heater from the service location. The licensing inspector verified this during a physical site review. 12/04/2024 Implemented
SIN-00217358 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)On 1/11/2023 the walkway leading to the exterior stairway on the side of the home have four cement pavers that are uneven, presenting a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. Operation Manager leveled the ground in front of step area where the pavers were placed for use of a sidewalk, Pavers were reset and OM assured they were level and no risk of trip/fall. [Documentation of the leveled-out walkway, via photograph, was received on 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/01/2023 Implemented
6400.181(a)Individual #1 was admitted on 3/3/2022 and the initial assessment was completed on 5/23/2022, 81 calendar days after admission. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Program Specialist, reviewed Programming regulations,(which included 6400.181(a)) to assure knowledge of required timelines. Signature/content was sent to HR Department. [Documentation of staff training related to initial and annual individual assessments, dated 1/30/23, was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 01/30/2023 Implemented
6400.214(b)On 1/11/23 Individual #1's most recent assessment and psychological evaluation were not present at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. On 1/11/2023, a RESIDENTIAL RECORDS binder was created: Binder contains Individual Demographics (ID Sheet), individual Assessments, most recent phycological evaluation, annual physical, dental hygiene plan, recent incident reports(90days) was placed in all service locations, this will assure compliance with 6400.214(b) 01/11/2023 Implemented
6400.165(b)Individual #1's, date of admission 3/03/2022, January 2023 Medication Administration Record states, "Ketoconazole 2% Shampoo, apply to scalp three times a week and let sit for five minutes and then rinse; taper to as needed with flares." The medication label states, "Ketoconazole 2% Shampoo, apply liberally as directed to scalp once per week." Individual #1's January 2023 Medication Administration Record states, "Benzoyl Peroxide, 5% Wash, use as a face wash at bedtime for acne." The medication label states, "Benzoyl Peroxide 5% Wash, apply a small amount to skin at bedtime for acne."A prescription order shall be kept current.Prescription for Ketoconazole 2% shampoo and Benzoyl Peroxide 5% were corrected on the MAR to match the prescription label on the prescribed medication. [Documentation of quarterly monitoring form the includes MAR checklist, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/09/2023 Implemented
6400.166(a)(2)Individual #1's January 2023 Medication Administration Record does not list the prescribing physician.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The MAR for Individual #1 was corrected to include the name of the prescribing physician. [Documentation of quarterly monitoring form the includes MAR checklist, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 01/16/2023 Implemented
SIN-00127856 Renewal 01/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The program specialist provided the assessment dated 7/13/17 for Individual #1 to the plan team members on 7/15/17 for the ISP meeting on 7/27/17(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Program Specialist will ensure the team receives the assessment 30 days prior to the annual ISP meeting, PS completed a reminder tickler system to communicate to her all documents are sent and what dates are they are sent out. Program Director will review Program Specialist records quarterly to ensure timeliness of documentation. [Documentation of quarterly audits by the Program Director of the Program Specialist tracking system shall be kept. At least quarterly for 1 year, the Program Director shall audit a 25% sample of correspondence documentation showing that the program specialist provided individuals' assessments to all individuals' plan team members at least 30 calendar days prior to the ISP meeting. Documentation of audits shall be kept. (AS 2/9/18)] 02/06/2018 Implemented
SIN-00088512 Renewal 01/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance has an expiration date of 12/5/15; the self-assessment was completed on 9/28/15.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The CEO reviewed regulation 6400.15(a) in regards to self-assessments. Valley Advantages will monitor time frames in which the regulation must be completed, assuring for 2016 all assessments will be completed between 6/5/2016-9/5/2016 [Immediately, CEO will develop and implement a system to alert as to when the self-assessment is due to be completed. CEO will monitor the alert system and review self-assessment to ensure timely completion. (AS 4/8/16)] 01/30/2016 Implemented
6400.71The telephone number for the nearest hospital and ambulance was not on or by the telephone in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Valley Advantages added to their list of Emergency Numbers, which is located by the phone in each location, the nearest hospital and ambulance phone numbers. See attachment 0001-C the CEO will conduct quarterly random audits at physical locations to assure compliance with all 6400 regulations. [Documentation of all audits shall be maintained. (AS 3/7/16)] 01/30/2016 Implemented
6400.181(d)The program specialist did not date Individual #1's current assessment.The program specialist shall sign and date the assessment. the Program Specialist reviewed all regulations pertaining to 6400.181 individual assessment. 6400.181 was added to the Program Specialist job description, all future assessments will be completed in compliance with regulation 161.181. The CEO will conduct random Audits to assure continued compliance with all 6400 regulations.[Individual #1's assessment was dated by the Program Specialist. Immediately and continuing at least quarterly, CEO will review all individuals' current assessments to ensure they are dated by the program specialist. Documentation of reviews shall be kept. (AS 4/8/16)] 01/21/2016 Implemented
SIN-00167335 Renewal 12/11/2019 Compliant - Finalized
SIN-00106664 Renewal 01/17/2017 Compliant - Finalized