Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253823 Renewal 08/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The front screen door lock is missing and there is tape covering the hole where the lock should have been. Screens, windows and doors shall be in good repair. The Lock was replaced on the same day of violation report was received. Pictures of the repair are recorded along with the maintenance request form that was put in place 08/21/2024 Implemented
SIN-00210374 Renewal 08/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Cases of soda and water were found stored with paint and Mold Armor E-Z House Wash in an unlocked cabinet in the basement. During the inspection, the food items were removed and stored separately from the poisonous materials.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.staff meeting conducted letting everyone know that all food even their personal food must be kept in kitchen area at all times and kept separate from any non food items 08/31/2022 Implemented
6400.76(c)Individual #1's bedroom dresser was missing several knobs on its drawers. Two knobs were missing from its upper left drawer; one from its middle left; one from its upper right; and two from its lower right drawers.Furniture shall be comfortable and home-like. All knobs were replaced on drawers will submit pictures to show. 08/31/2022 Implemented
6400.82(f)Individual #1's bathroom did not have a mirror.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Mirror was placed back into individuals bathroom 08/31/2022 Implemented
6400.111(a)The basement fire extinguisher was under charged according to the gauge at its top. After the inspection, the agency provided a photograph showing the extinguisher had been replaced with one that was charged properly.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. under charged fire extinguisher was replaced with properly charged one within the same 30 minutes 08/31/2022 Implemented
6400.144Individual #2's medication administration record (MAR) does not clearly indicate that their prescribed medication, ketoconazole cream was administered at 8AM from 8/19/22 -- 8/21/22. On 8/19 and 8/20, there are no staff signatures on the MAR, only slashes; on 8/21, the MAR is blank. The MAR contained no notes regarding missed dosages or explaining the slashes on 8/19 and 8/20.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All staff has been given a refresher course on MAR Abbreviation and double check form has been put in place 09/01/2022 Implemented
SIN-00192849 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Individual #1 (D.O.H) 10/02/18-The physical exam for this staff member was not completed w/in the required 2-year timeframe-(6/4/19, 6/21/21). A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. We Have monitored all staff member charts and we will ask that all staff members have full physicals completed within 120 days of their current expiration date of previous two years, If not completed staff will be removed from schedule 09/15/2021 Implemented
SIN-00149391 Renewal 01/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The Physical for individual # 1dated 11/6/18 did not assess health maintenance needs.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. Program Specialist will ensure that all Individuals Health maintenance needs are documented on Physical at annual physical review 02/05/2019 Implemented
6400.141(c)(14)The Physical for individual # 1dated 11/6/18 did not assess medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Specialist had doctor update Physical on 2/5/2019. will ensure that this is documented on physical examination at the time of annual physical by doctor 02/05/2019 Implemented
6400.142(h)Individual #1's dental hygiene plan was not available in the record. The dental hygiene plan shall be kept in the individual's record.Dental Hygiene Plan has been placed in individual's record. Program Specialist will ensure this is updated annually and as needed 02/05/2019 Implemented
6400.181(e)(5)Individual #1's assessment dated 12/2/17 did not evaluate their ability to self-administer medication.The assessment must include the following information:  The individual's ability to self-administer medications.Program Specialist has updated current assessment to reflect ability to administer medication 02/05/2019 Implemented
6400.183(4)The ISP for individual # 1 did not have a protocol outlining time without direct supervision.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Program Specialist has reached out to Support Coordinator to have the isp updated, she was informed that it will be completed by 3-4-2019 03/04/2019 Implemented
SIN-00175124 Renewal 08/18/2020 Compliant - Finalized