Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281456 Renewal 01/14/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)On 1/15/2026 at 11:28AM, the hot water handle was broken on the top and hanging downward at the sink in the kitchen of the home.Floors, walls, ceilings and other surfaces shall be in good repair. On 1/15/2026, CEO emailed the maintenance team at Eagle Ridge and submitted another request for the handle on sink faucet. On 1/16/2026 the handle was replaced. 01/16/2026 Implemented
6400.68(a)On 1/15/2026 at 11:30AM, the hot water temperature measured 89.9 degrees Fahrenheit at the sink in the kitchen of the home. At 11:40AM, the hot water temperature measured 86.9 degrees Fahrenheit at the bathtub in the bathroom in the hallway of the home.A home shall have hot and cold running water under pressure. On 1/15/2026, Management team reached out to the Eagle Ridge Maintenance team to address the water being under pressure. Maintenance team came to checked the water heater, turned up the water heater and relit the pilot. due to the water heater being down to a lower temp in which the pilot went out. Management team checked the pressure and water twice that day 5pm being 101 degrees and 9pm being 110 degrees. 01/15/2026 Implemented
6400.107On 1/16/2026 at 11:35AM, a portable space heater was on a shelf in the closet in the living room of the home.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The portable space heater was removed immediately from the home and taken to the agency main office until the owner has been identified to make arrangements to pick it up. The site was examined to assure no additional portable heaters were on the premises. Staff was trained on regulation 6400.107. Reminders were sent to the staff. Management will check the site weekly doing checks to ensure no heaters are on premises. 01/16/2026 Implemented
6400.32(d)On 1/15/2026 at 11:30AM, signs on the back of the kitchen cabinets, facing the living room of the home read, "Please Keep [Individual #1 on [their] schedule. 6:00-6:30PM-[Individual #1] starts [their] dinner-[Individual #1] cleans up after [their] self and staff is expected to do the same-[Individual #1] gets [their] shower at 8:00PM! (brushes teeth, wipes mirror, does face treatment, gets school clothes out) and any choses. 9:30PM-[Individual #1] goes to bed! lights out, phone put with staff, down for night. During day-[Individual #1] likes to take walks, get exercise, swim, play games and be active.-[Individual #1] likes to cook with staff assistance -and gets phone and iPad privileges as a Reward for doing as [Individual #1] is supposed to. -[Individual #1] gets very little prompts to do these things because it's [Individual #1's] regular routine." "Staff check [Individual #1's] cups at end of shift! [Individual #1] sometimes leaves juice in the cups and it's a horrible smell when left untouched! Check cupboards for dirty dishes and clean up personal belongings!! Please remember this is someone's home!! And Respect it as such!!" "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray. [Individual #1] does these this on [their] own! Staff checks when done." "[Individual #1] turns in iPad at 9:00pm. [Individual #1] goes to bed with TV OFF!! And Both remotes turned in at 9:30pm NO EXCEPTIONS!! Weekdays and Weedends!" At 11:40AM, there was a sign on Individual #1's bedroom that read, "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray." At 11:41AM, there was a sign on the outside of Individual #1's bedroom door facing the hallway of the home that read, "At 9:30pm Please remove both remote controls from [Individual #1's] room. And turn TV and all lights out. -Please remind [Individual #1] at 8:00pm to take [their] shower and wind down for the night."An individual shall be treated with dignity and respect.On 1/15/2026, all the signs were taking down. On the same day, Humans Right Violation was entered into the EIM due to the individuals rights being violated. The Human Rights Team met 1/22/26 to address the concern due to teams concerns about the individual having difficulty with his bedroom routine/hygiene due to being on the internet all night for concern of being on inappropriate websites. The HRC committee agreed for a Restrictive Pan for Bedroom routing and staff support for him utilizing the internet safely. The Restrictive Plan was written, completed, signed and approved by the HRC. The staff were trained on the Plan and regulations. 01/22/2026 Implemented
6400.32(g)On 1/15/2026 at 11:30AM, signs on the back of the kitchen cabinets, facing the living room of the home read, "Please Keep [Individual #1 on [their] schedule. 6:00-6:30PM-[Individual #1] starts [their] dinner-[Individual #1] cleans up after [their] self and staff is expected to do the same-[Individual #1] gets [their] shower at 8:00PM! (brushes teeth, wipes mirror, does face treatment, gets school clothes out) and any choses. 9:30PM-[Individual #1] goes to bed! lights out, phone put with staff, down for night. During day-[Individual #1] likes to take walks, get exercise, swim, play games and be active.-[Individual #1] likes to cook with staff assistance -and gets phone and iPad privileges as a Reward for doing as [Individual #1] is supposed to. -[Individual #1] gets very little prompts to do these things because it's [Individual #1's] regular routine." "Staff check [Individual #1's] cups at end of shift! [Individual #1] sometimes leaves juice in the cups and it's a horrible smell when left untouched! Check cupboards for dirty dishes and clean up personal belongings!! Please remember this is someone's home!! And Respect it as such!!" "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray. [Individual #1] does these this on [their] own! Staff checks when done." "[Individual #1] turns in iPad at 9:00pm. [Individual #1] goes to bed with TV OFF!! And Both remotes turned in at 9:30pm NO EXCEPTIONS!! Weekdays and Weedends!" At 11:40AM, there was a sign on Individual #1's bedroom that read, "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray." At 11:41AM, there was a sign on the outside of Individual #1's bedroom door facing the hallway of the home that read, "At 9:30pm Please remove both remote controls from [Individual #1's] room. And turn TV and all lights out. -Please remind [Individual #1] at 8:00pm to take [their] shower and wind down for the night." Individual #1 is being restricted from controlling their own schedule and activities.An individual has the right to control the individual's own schedule and activities.All the signs were taken down (1/15/2026). The Human Rights Team met 1/22/26 to address the concern due to teams concerns about the individual having difficulty with his bedroom routine/hygiene due to being on the internet all night for concern of being on inappropriate websites. The HRC committee agreed for a Restrictive Pan for Bedroom routing and staff support for him utilizing the internet safely. The Restrictive Plan was written, completed, signed and approved by the HRC. The staff were trained on the Plan and regulations. 01/22/2026 Implemented
6400.32(i)On 1/15/2026 at 11:30AM, signs on the back of the kitchen cabinets, facing the living room of the home read, "-[Individual #1] likes to cook with staff assistance -and gets phone and iPad privileges as a Reward for doing as [Individual #1] is supposed to." "[Individual #1] turns in iPad at 9:00pm. [Individual #1] goes to bed with TV OFF!! And Both remotes turned in at 9:30pm NO EXCEPTIONS!! Weekdays and Weedends!" At 11:41AM, there was a sign on the outside of Individual #1's bedroom door facing the hallway of the home that read, "At 9:30pm Please remove both remote controls from [Individual #1's] room. And turn TV and all lights out. -Please remind [Individual #1] at 8:00pm to take [their] shower and wind down for the night." Staff interviews revealed that Individual #1's iPad is being taken away in the evenings due to concerns about Individual #1 attempting to access Child Pornography. Individual #1 does not have a Restrictive Procedure Plan that has been approved by a Human Rights Team.An individual has the right of access to and security of the individual's possessions.On 1/15/2026, all the signs were taking down. On the same day, Humans Right Violation was entered into the EIM due to the individuals rights being violated. The Human Rights Team met 1/22/26 to address the concern due to teams concerns about the individual having difficulty with his bedroom routine/hygiene due to being on the internet all night for concern of being on inappropriate websites. The HRC committee agreed for a Restrictive Pan for Bedroom routing and staff support for him utilizing the internet safely. The Restrictive Plan was written, completed, signed and approved by the HRC. The staff were trained on the Plan and regulations. 01/22/2026 Implemented
6400.166(b)Individual #1's prescribed medication, Methylphenidate, was not initialed as administered on 1/4/2026 at 12:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The identified staff was retrained on the 7 medication rights(Right Medication, Right individual, Right Dose, Right Time, Right Route, Right Reason, Right Documentation. The staff was retrained on medication policy and procedures and retrained on the regulation 6400.166(b) and subsection (a)(12) and (13) The staff also received a documentation error. The identified staff was observed by agency med trainer completing a medication pass. 01/23/2026 Implemented
6400.195(a)On 1/15/2026 at 11:30AM, signs on the back of the kitchen cabinets, facing the living room of the home read, "Please Keep [Individual #1 on [their] schedule. 6:00-6:30PM-[Individual #1] starts [their] dinner-[Individual #1] cleans up after [their] self and staff is expected to do the same-[Individual #1] gets [their] shower at 8:00PM! (brushes teeth, wipes mirror, does face treatment, gets school clothes out) and any choses. 9:30PM-[Individual #1] goes to bed! lights out, phone put with staff, down for night. During day-[Individual #1] likes to take walks, get exercise, swim, play games and be active.-[Individual #1] likes to cook with staff assistance -and gets phone and iPad privileges as a Reward for doing as [Individual #1] is supposed to. -[Individual #1] gets very little prompts to do these things because it's [Individual #1's] regular routine." "Staff check [Individual #1's] cups at end of shift! [Individual #1] sometimes leaves juice in the cups and it's a horrible smell when left untouched! Check cupboards for dirty dishes and clean up personal belongings!! Please remember this is someone's home!! And Respect it as such!!" "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray. [Individual #1] does these this on [their] own! Staff checks when done." "[Individual #1] turns in iPad at 9:00pm. [Individual #1] goes to bed with TV OFF!! And Both remotes turned in at 9:30pm NO EXCEPTIONS!! Weekdays and Weedends!" At 11:40AM, there was a sign on Individual #1's bedroom that read, "[Individual #1's] Chores (8pm) -Clean dishes as used -clean dining room table -vacuum floors -clean room -clean [Individual #1's] mirror and sink -Clean Toilet (staff cleans bathroom after use) -Spray door knobs etc.... with disinfectant spray." At 11:41AM, there was a sign on the outside of Individual #1's bedroom door facing the hallway of the home that read, "At 9:30pm Please remove both remote controls from [Individual #1's] room. And turn TV and all lights out. -Please remind [Individual #1] at 8:00pm to take [their] shower and wind down for the night." Staff interviews revealed that these restrictions are being implemented due to Individual #1's behaviors. Individual #1 does not have a Restrictive Procedure Plan that has been reviewed and approved by a Human Rights Team.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.On 1/15/2026, all the signs were taking down. On the same day, Humans Right Violation was entered into the EIM due to the individuals rights being violated. The Human Rights Team met 1/22/26 to address the concern due to teams concerns about the individual having difficulty with his bedroom routine/hygiene due to being on the internet all night for concern of being on inappropriate websites. The HRC committee agreed for a Restrictive Pan for Bedroom routing and staff support for him utilizing the internet safely. The Restrictive Plan was written, completed, signed and approved by the HRC. The staff were trained on the Plan and regulations. 01/22/0206 Implemented
SIN-00200272 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature in the bath tub in the only bathroom in the home measured 144.9 degrees F at 10:49 am.Hot water temperatures in bathtubs and showers may not exceed 120°F.On February 17, 2022, the hot water tank was adjusted by the DHS ODP Licensing Lead Representative and QACS staff, in order to lower the water temperature. The temperature was later checked by the QACS staff that came in at 3pm, at that time the temperature was at 116°F. 02/16/2022 Implemented
6400.18(a)(5)Incident #8914919, categorized as neglect, was discovered on 10/3/21 and reported to the Department's information management system on 10/5/21.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. The provider is aware of the untimely reporting as indicated in the QACS Quarterly IM Report. In the future the agency will report the following incidents, alleged incidents and suspected incidents through the department's information management system (EIM) or on a form (contingency report) specified by the Department within 24 hours of discovery by a staff person. 02/21/2022 Implemented
6400.18(i)Incident #8914919 reported on 10/5/2021 was finalized on 1/19/22. No extensions were requested.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The provider reclassified incident 8902329 from missing person to neglect as advised and conducted the certified investigation as indicated in the ODP IM Bulletin. In the future the agency will report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person. 02/21/2022 Implemented
SIN-00128515 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The psychiatric medication reviews for Individual #1 completed 8/1/17, 9/1/17 and 12/1/17 did not include the reason for prescribing the medication and the need to continue the medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Plan of Correction for: PA 6400.163 (c) Use of Prescription Medications How was it Corrected: On February 9, 2018, The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade will have Quality Adult Care Services psychiatric medication review forms were revised to include the previous specified diagnosis from the psychiatrist. Program Specialist Supervisor had the revised form completed and signed by Individual #1 Psychiatrist. When it was corrected: On February 9, 2018. Who made the corrections: Program Supervisor; Leslie Law-Ball Took revised form to the psychiatrist to complete. What Specific Change will be made: The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade will ensure all components of the psychiatric medication review form are fully completed with the reason for prescribing the medication and the need to continue the medication. Who will make the change: The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade When will the change be made: This will be completed by February 9th 2018 How will the change be made: The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade, will review the form with the psychiatrist for accuracy. What system have you implemented to make sure that the same violation will not occur again: The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade will review quarterly for compliance What training will be provided by you staff: The Program Specialist Supervisor; Leslie Law-Ball, Program Specialist; Anisa Tate, Program Supervisor; Tamica Wade will train the direct care staff on the QUALITY ADULT CARE SERVICES psychiatric medication review form the importance of how the forms needs to be accurately completed with all required information. Supporting Documentation:Training Agenda Form Updated Psychiatric Medication Form 02/16/2018 Implemented
SIN-00260918 Renewal 02/19/2025 Compliant - Finalized
SIN-00169423 Renewal 01/15/2020 Compliant - Finalized
SIN-00107951 Renewal 02/06/2017 Compliant - Finalized