Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254966 Renewal 11/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)There was a cardboard rodent glue trap and black rodent bait station located in the attic that had a large area of mouse nesting material and mouse droppings around them, indicating an issue with infestation.There may not be evidence of infestation of insects or rodents in the home. Pest control will continue to come out quarterly. 12/18/2024 Implemented
6400.112(c)The fire drill records did not indicate if there were problems encountered or not for the entire year.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 fire drill record will include the question: Were there any concerns or problems during the drill period? If yes describe in detail 12/01/2024 Implemented
SIN-00233593 Renewal 11/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were washcloths and papers that had fallen in between the clothes dryer and file cabinet that need to be cleaned out to prevent a potential fire hazard.Clean and sanitary conditions shall be maintained in the home. Washcloths and papers were cleaned up immediately. 02/14/2024 Implemented
SIN-00178274 Renewal 10/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Dryer lint the size of a golf ball when rolled was found in the lint trap of the dryer in the first floor laundry room at the time of physical site review Floors, walls, ceilings and other surfaces shall be free of hazards.House Supervisor, corrected the dryer lint problem. She posted a note to all staff in the communication book immediately on inspection day 10/21/2020 about the fire hazard. Anne also posted a laminated sign next to the dryer that states-Please check dryer lint trap after every use. 10/21/2020 Implemented
SIN-00150673 Renewal 02/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The outdoor porch carpet was found in poor condition. The carpet was found hazardous due to wet and slippery weather conditions. Floors, walls, ceilings and other surfaces shall be free of hazards.The carpet was removed. The pavement will be painted with gritty paint to ensure it is not slippery. 04/16/2019 Implemented
SIN-00094675 Renewal 05/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff # 3 completed fire safety training on 4/20/16 and it was not conducted by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). All director's, program specialist and supervisors will be trained by a fire safety expert on 9/8/16. All staff and individuals will be trained after supervisors will be trained..[Quality Manager/Program Designee will ensure that all staff are annually trained on fire safety by a fire safety expert by developing a tracker of all required annual trainings. Program director/program designee will complete quarterly audits of the tracker, it's completion, and the resulting training for all staff of the program. The process will begin within fifteen days of receipt of this plan of correction DD 9.20.16] 10/14/2016 Implemented
6400.67(a)There was a heavily scuffed area approximately one foot by one foot on the wall behind the recliner located in the living room.Floors, walls, ceilings and other surfaces shall be in good repair. Pam Hoffman (Residential Director) placed a work order to the agency and had the scuffed wall behind the recliner sanded and repainted. The wall was repainted on 6/20/16. In the future work orders will be placed to the maintenance department and repaired.[Quality Manager or Program Designee will complete monthly walk through/checks of the licensed home to ensure all walls, floors, ceilings and other surface areas are in good repair. If areas are found to not be in good repair a maintenance order will immediately be submitted and weekly follow up until it's repaired. Additionally Program Director will complete quarterly audits of the monthly checks to ensure monthly checks are occurring and with maintenance follow up beginning within fifteen days of receipt of this plan of correction DD 9.20.16] 06/20/2016 Implemented
6400.76(a)There were tears which exposed the padding on the arm of the recliner located in the living room. Furniture and equipment shall be nonhazardous, clean and sturdy. Pam Hoffman (Residential Director) will ensure that furniture is clean and sturdy. Any tears in the future will be reported to the CEO and either replaced or patched. The recliner that was torn was replaced on 06/22/2016. A brand new recliner was purchased for the home. [Quality Manager or Program Designee will complete monthly walk through/checks of all licensed homes to ensure all areas are nonhazardous, clean and sturdy. If areas are found to not be free of hazards, clean nor sturdy a maintenance order will immediately be submitted and weekly follow up until it's repaired. Additionally Program Director will complete quarterly audits of the monthly checks to ensure monthly checks are occurring and with maintenance follow up beginning within fifteen days of receipt of this plan of correction DD 9.20.16] 06/22/2016 Implemented
6400.113(a)Individual # 3 completed fire safety training on 4/01/16 and it was not conducted by a fire safety expert. 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. All director's, program specialist and supervisor's will be trained by a fire safety expert on 9/9/16. All trained staff will be training individuals and staff.[Quality Manager/Program Designee will ensure that all individuals upon admission complete fire safety training by developing a tracker of all required trainings upon admission. Additionally, the tracker will be utilized annually to ensure that thereafter each individual receives continued fire safety training annually. Program director/program designee will complete quarterly audits of the tracker, it's completion, and the resulting training for all individuals of the program. The process will begin within fifteen days of receipt of this plan of correction DD 9.20.16] 10/14/2016 Implemented
6400.141(a)Individual # 3's previous physical examination was dated 9/17/14 and the most recent physical examination was dated 10/21/15.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Pam Hoffman (Residential Director) will ensure that the supervisor makes an earlier appointment for a physical examination for an individual in the event the doctor office cancels the appointment. If an appointment needs to be rescheduled it will be within the 15 day grace period. [Quality Manager/Program Designee will ensure that all individuals have an up to date physical within their record. Additionally, a tracker will be utilized to ensure that each individuals medical appointments and necessary follow up or annual visit is known to all staff that support the individual in advance of the due date. Program director/program designee will complete quarterly audits of the tracker, its accuracy, completion and ensure that information is being relayed to supervisors timely. The process will begin within fifteen days of receipt of this plan of correction DD 9.20.16] 08/17/2016 Implemented
SIN-00078773 Renewal 02/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)The prescribed drug "Fluticasone Propionate Cream" is labeled to be applied at 8am and 8pm as needed. These directions were not noted on the medication log.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Fluticasone Propionate Cream was added to the medication log to match the label on the medication. The Program Specialist will check the Medication Administration Log monthly to ensure that all medications and treatments are noted on the log. The Program Director will conduct periodic reviews of the Medication Administration log to ensure that required documentation is noted on the medication log. Staff that administer medications and treatments will be trained on the importance of acurate documentation on the medication log within 30 days of receipt of this plan of correction. [SW 5.27.15] 02/11/2015 Implemented
SIN-00057115 Renewal 11/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was used to exit during fire drills on: 10/04/13, 9/30/13, 8/31/13, 7/17/13, 6/27/13, 5/24/13, 3/13/13, 2/23/13, 1/27/13, 12/29/12, 11/12/12, 10/20/12. (f) Alternate exit routes shall be used during fire drills. A new form was created to ensure that exits routes are used and will be checked by supervisor/ house manager. Rotating exits were discussed with house staff on 11/21/13. The form will be implemented by December 11, 2013. The director/ assistant director will be going over the form with the house managers at a meeting on 12/10/13. 12/11/2013 Implemented
SIN-00272121 Renewal 08/18/2025 Compliant - Finalized
SIN-00214310 Renewal 11/02/2022 Compliant - Finalized
SIN-00196110 Renewal 11/03/2021 Compliant - Finalized
SIN-00205475 Renewal 11/03/2021 Compliant - Finalized
SIN-00124610 Renewal 11/17/2017 Compliant - Finalized