| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00267657
|
Unannounced Monitoring
|
06/05/2025
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 11:19AM, there was grease residue and burnt food chards at the bottom and along the sides in the airfryer on the counter in the kitchen of the home. At 11:21AM, there was thick, black residue on the floor, on the shelf and on the heating register beside the stove in the kitchen of the home. At 11:22AM, there was a half-inch thick layer of dust on and around the power cord and a thick layer of black residue behind and next to the refrigerator in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | Actions Taken to Resolve the Issue:
The air fryer was cleaned and degreased.
The floor, shelf, heating register, and surrounding kitchen areas were thoroughly sanitized.
Dust and residue were removed from the refrigerator area and power cord.
A complete kitchen deep clean was performed the same day. |
06/15/2025
| Not Implemented |
| 6400.67(a) | At 11:16AM, the pantry shelf at the bottom on the left side of the kitchen of the home was not attached to the screws in the wall behind it and leaning toward the floor. | Floors, walls, ceilings and other surfaces shall be in good repair. | Actions Taken to Resolve the Issue:
All maintenance issues were reported to our Contractor, who is scheduled to complete the necessary repairs¿including securing the pantry shelf, resealing the window unit, tightening or replacing the porch railing, and leveling the walkway bricks¿by 6/23/2025.
A ticket was submitted to our Landscaping Company for the trimming of the overgrown bushes. We are on their schedule for July, and they will notify us during that week with the exact day and time they plan to complete the work. We are also on their cancellation list and may be serviced sooner if an earlier slot becomes available.
Responsibility & Compliance Monitoring:
Supervisors will oversee the Contractor to ensure timely progress and completion of repairs.
The Program Specialist will conduct monthly inspections using the Quality and Assurance Checklist.
House Managers will review the Maintenance Request Log weekly to ensure all issues are addressed and resolved promptly. |
06/23/2025
| Implemented |
| 6400.72(a) | At 11:32AM, there was an air conditioning unit in the window in the dining room of the home surrounding by black duct tape leaving a quarter-inch gap at the bottom on each side allowing space for insects to enter the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Actions Taken to Resolve the Issue:
All maintenance issues were reported to our Contractor, who is scheduled to complete the necessary repairs¿including securing the pantry shelf, resealing the window unit, tightening or replacing the porch railing, and leveling the walkway bricks¿by 6/23/2025.
A ticket was submitted to our Landscaping Company for the trimming of the overgrown bushes. We are on their schedule for July, and they will notify us during that week with the exact day and time they plan to complete the work. We are also on their cancellation list and may be serviced sooner if an earlier slot becomes available.
Responsibility & Compliance Monitoring:
Supervisors will oversee the Contractor to ensure timely progress and completion of repairs.
The Program Specialist will conduct monthly inspections using the Quality and Assurance Checklist.
House Managers will review the Maintenance Request Log weekly to ensure all issues are addressed and resolved promptly. |
06/23/2025
| Implemented |
| 6400.73(a) | At 12:38PM, the wooden railing, on the right side connected to the four-exterior, wooden stairs leading to the front porch of the home, is loose and moves when in use. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Actions Taken to Resolve the Issue:
All maintenance issues were reported to our Contractor, who is scheduled to complete the necessary repairs¿including securing the pantry shelf, resealing the window unit, tightening or replacing the porch railing, and leveling the walkway bricks¿by 6/23/2025.
A ticket was submitted to our Landscaping Company for the trimming of the overgrown bushes. We are on their schedule for July, and they will notify us during that week with the exact day and time they plan to complete the work. We are also on their cancellation list and may be serviced sooner if an earlier slot becomes available.
Responsibility & Compliance Monitoring:
Supervisors will oversee the Contractor to ensure timely progress and completion of repairs.
The Program Specialist will conduct monthly inspections using the Quality and Assurance Checklist.
House Managers will review the Maintenance Request Log weekly to ensure all issues are addressed and resolved promptly. |
06/23/2025
| Implemented |
| 6400.80(a) | At 12:18PM, two of the bricks in the walkway at the back exit of the home were sunken downward approximately one-inch from the adjoining bricks posing a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Actions Taken to Resolve the Issue:
All maintenance issues were reported to our Contractor, who is scheduled to complete the necessary repairs¿including securing the pantry shelf, resealing the window unit, tightening or replacing the porch railing, and leveling the walkway bricks¿by 6/23/2025.
A ticket was submitted to our Landscaping Company for the trimming of the overgrown bushes. We are on their schedule for July, and they will notify us during that week with the exact day and time they plan to complete the work. We are also on their cancellation list and may be serviced sooner if an earlier slot becomes available.
Responsibility & Compliance Monitoring:
Supervisors will oversee the Contractor to ensure timely progress and completion of repairs.
The Program Specialist will conduct monthly inspections using the Quality and Assurance Checklist.
House Managers will review the Maintenance Request Log weekly to ensure all issues are addressed and resolved promptly. |
06/23/2025
| Implemented |
| 6400.80(b) | At 12:19PM, the bushes next to the walkway outside of the back exit were overgrown approximately five inches over the walkway. At 12:38PM, the wood and paint were chipping from the wooden railing leading to the porch in the front of the home posing the risk of splintering when in use. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Actions Taken to Resolve the Issue:
All maintenance issues were reported to our Contractor, who is scheduled to complete the necessary repairs¿including securing the pantry shelf, resealing the window unit, tightening or replacing the porch railing, and leveling the walkway bricks¿by 6/23/2025.
A ticket was submitted to our Landscaping Company for the trimming of the overgrown bushes. We are on their schedule for July, and they will notify us during that week with the exact day and time they plan to complete the work. We are also on their cancellation list and may be serviced sooner if an earlier slot becomes available.
Responsibility & Compliance Monitoring:
Supervisors will oversee the Contractor to ensure timely progress and completion of repairs.
The Program Specialist will conduct monthly inspections using the Quality and Assurance Checklist.
House Managers will review the Maintenance Request Log weekly to ensure all issues are addressed and resolved promptly. |
06/23/2025
| Implemented |
| 6400.111(f) | The fire extinguishers on each floor of the three-story home was most recently inspected and approved by a fire safety expert in 3/2024. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Actions Taken to Resolve the Issue:
All fire extinguishers in the home were inspected and re-certified by a certified vendor on 6/5/2025.
The Supervisor responsible for conducting home inspections was formally written up for failing to identify the expired extinguisher certifications.
On-site Supervisors and relevant staff participated in refresher training focused on completing thorough and accurate home inspections, specifically ensuring they are actually checking fire extinguishers during each inspection rather than relying on memory.
The Supervisor acknowledged awareness of the need for inspection and explained that while the appointment had been scheduled, an unrelated incident caused a delay, and the task was unintentionally missed.
Responsibility & Compliance Monitoring:
Supervisors will inspect fire extinguishers for current certification tags during their bi-weekly site inspections.
The Program Specialist will perform monthly quality assurance checks using the Quality and Assurance Checklist. |
06/05/2025
| Implemented |
| 6400.192 | Staff interviews revealed that the sharps and lighters are locked and kept from Individual #1 due to behavioral concerns. Individual #1 does not have a restrictive procedure plan. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | Actions Taken to Resolve the Issue:
A team meeting was held on 6/14/2025 to address the issue and determine how to support WH without implementing restrictive procedures.
The agency¿s smoking policy was updated to reflect the use of safety lighters as the preferred method for lighting cigarettes, promoting safety while respecting individual rights.
Sharps were removed from the locked staff closet and are now regularly available in the kitchen for appropriate household use.
All staff have completed a refresher training on Individual Rights, including the proper use and approval process for any restrictive interventions.
Responsibility & Compliance Monitoring:
The Program Specialist is responsible for ensuring ongoing compliance with WH¿s rights and confirming that no restrictions are implemented without formal approval.
Supervisors will conduct routine site visits and staff interviews to verify adherence to rights-based supports and updated policies.
Any unauthorized restriction will be reported to management and addressed immediately. |
06/14/2025
| Not Implemented |
|
|
|
SIN-00258010
|
Unannounced Monitoring
|
12/18/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:42AM on 12/18/2024, deceased insects, dirt and other debris lined the floor along the baseboards and corners of the bathroom in the basement of the home. | Clean and sanitary conditions shall be maintained in the home. | We received this violation because the baseboard and corners of basement were not adequately cleaned. To resolve, Cleaned baseboards of the basement on 12/19/2024. Direct Care Saff, House manager/Supervisors are responsible for fixing the problem and monitoring the compliance |
01/10/2025
| Implemented |
| 6400.76(a) | At 10:35AM, the front, left side of the cabinet on the left side of the kitchen of the home was covered in black duct tape to keep it attached. The cabinet on the right side of the kitchen had a piece of plywood covering the middle and a broken piece of wood along the bottom frame that reportedly happened from a behavioral incidents months ago. | Furniture and equipment shall be nonhazardous, clean and sturdy. | We had a cabinet door that was damaged. The other cabinet door was repaired with Plywood.
What did we do right now to fix the problem? We had the cabinet door repaired by professional. House Managers and Supervisors are responsible for fixing the problem and monitoring the compliance. |
12/29/2023
| Implemented |
| 6400.114(b) | The provider's written smoking policy states, "staff or visitors are to properly dispose of all cigarette butts in a receptacle with lid." At 10:55AM on 12/18/2024, a partially smoked cigarette was on a wooden shelf and cigarette ashes were on the floor next to the couch in the living room of the home. [Repeat Violation, 4/20/2023, 6/29/2023] | Written smoking safety procedures shall be followed. | We received this violation on 12/18/24 because a smoked cigarette along with the ashes was not disposed appropriately as stated in the smoking policy. Staff will assure that the all-cigarette butts and or ashes will be disposed in the correct manner and will prompt individual on following the right approach if deemed necessary. The partially smoked cigarette and ashes in the living room and was disposed of in the precise site as stated per smoking policy immediately. |
01/05/2025
| Implemented |
| 6400.143(a) | At 10:09AM on 12/18/2024, Direct Service Worker #1 was observed writing "R" on each 9AM medication on the December 2024 Medication Administration Record. When asked about this action, Direct Service Worker #1 stated, "[Individual #1] refused all meds this morning. I tried to wake [Individual #1] up and [Individual #1] wouldn't get up. So I'm writing up the refusals." It was also revealed that Individual #1's physician was not contacted and counseling
of Individual #1 was not attempted nor documented. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | We received this violation because the staff did not repeatedly administer counseling to an individual that refused their medication. We updated our refusal form to display the actions were taken to educate the individual on medications. Additionally, we are updating our Physicians instructions on what actions to take when an individual refuses to take their medication. To fix the issue, we updated our Refusals form to represent specifically what to do when an individual refuses a medication and the counseling that should be conducted while the individual is actively refusing the medication |
01/22/2025
| Implemented |
| 6400.171 | At 10:08AM on 12/18/2024, a partially used bag of Gorton's frozen fish fillets was unsealed in the freezer in the kitchen of the home. [Repeat Violation, 12/22/20222, et. al.] | Food shall be protected from contamination while being stored, prepared, transported and served.
| This violation was received due to having unsealed food not properly stored in the freezer at home. The used bag of Gorton¿s frozen fish fillets was removed from freezer and was appropriately stored in sealed bag and labeled. Staff(DCS & House managers) were retrained on how to correctly store all food, the unsealed bag was removed from the freezer and stored appropriately. DCS and House managers are responsible for fixing the problem and monitoring the compliance |
12/29/2024
| Not Implemented |
| 6400.32(r)(4) | At 10:50AM on 12/18/2024, the staff key to Individual #1's bedroom door was not clearly marked and staff had to attempt to use several other keys prior to finding the correct key to unlock the door while Individual #1 was inside. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | We received this violation due to the keys were not labeled correctly. Managers/ House managers are responsible for fixing the problem and monitoring the compliance. |
01/10/2025
| Implemented |
|
|
|
SIN-00254116
|
Unannounced Monitoring
|
10/02/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | At 10:26AM, the front panel of the heating registers in the living room and dining room of the home was detached at the bottom and protruded approximately three inches posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | We received this violation due to heating register covers from the bottom were slightly off. The Director is responsible for resolving this issue. Director is responsible for fixing the problem and monitoring the compliance |
10/22/2024
| Not Implemented |
| 6400.72(b) | At 10:55AM, the air conditioning unit in the window in the living room of the home was partially sealed with duct tape with approximately one half-inch of space one the right side of the window. [Repeat Violation, 12/22/2022, 6/29/2023, 7/25/2023} | Screens, windows and doors shall be in good repair. | We received this violation because the AC although seated properly was not completely sealed on one side. Responsibility lies on the House Manager to document and report to the maintenance team. Managers, supervisors, and program specialists will make sure this is not an issue and track the maintenance ticket until completed in a timely manner. We had our maintenance tech remove the window A/Cs from the windows for the winter. We will have someone else install the window a/c units properly next year. This will also be monitored by technicians to make sure it is compliant and meet all safety standards. |
10/20/2024
| Implemented |
| 6400.73(a) | At 10:45AM, the railing at the bottom left side of the interior stairs leading to the second floor of the home was unsturdy and wobbled back and forth when in use. [Repeat Violation, 4/20/2023] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | We received this violation due railing was considered wobbly. Responsibility lies on the House Manager. Managers, supervisors, and program specialists will make sure daily checks are performed everyday using specific tools. We had the handrail removed because there is a properly functioning hand rail on the other side of the stairwell. |
10/12/2024
| Not Implemented |
| 6400.141(c)(3) | Individual #1's most recent Tetanus immunization was completed on 1/20/2009. [Repeat Violation, 12/20/2022] | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | We received this violation due to WH not getting his Tetanus shot since 2009. WH has refused to get this shot and we have it documented along with a training that was focused on getting WH to be comfortable with getting shots. WH is still currently refusing to get his shot we spoke with his behavior specialist who stated that she will continue working with WH to get him to take his shots. Responsibility lies on the Program Specialist & Director. Supervisors will assist and support any documentation needed to stay in compliance. |
10/12/2024
| Implemented |
| 6400.163(g) | At 10:31AM, one of Individual #1's Trazodone tablets was loose and at the bottom of the medication box. [Repeat Violation, 12/22/2022] | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | We received this violation due to staff dropping a tablet in medication box after passing meds on 10/2/2024. Responsibility lies on the House Manager & Med passer for that particular location |
11/01/2024
| Implemented |
|
|
|
SIN-00241195
|
Unannounced Monitoring
|
03/19/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | Individual #1's physical examination, completed 10/12/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. [Repeat Violation, 12/22/2022] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | We received this violation because one field was overlooked by dsp and office assistant once submitted. We thoroughly reviewed the individuals Physicals and resubmitted them to the respective Physicians to be fully filled out in the required fields. This issue was resolved as soon as it was noted on 3/19/24 |
03/19/2024
| Implemented |
|
|
|
SIN-00233415
|
Unannounced Monitoring
|
10/23/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | On 10/23/23, the smoke detectors of this 3-floor home were found to be not interconnected at 11:15 AM, 11:17 AM, and 11:19 AM. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | This violation occurred due to current personnel not being trained on how to properly set off the inline smoke detectors during inspection.
Who is responsible for fixing the problem and monitoring the compliance: Director, Program specialist.
What action that person will take: PS/Director reached out to supervisors and managers to confirm that the devices were in working order when they tested them. Program specialist went out to check if smoke detectors were in working order. |
10/24/2023
| Not Implemented |
|
|
|
SIN-00227549
|
Unannounced Monitoring
|
06/29/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 12:09PM, there was a layer to dust and debris from appears to be construction. In addition, there were two trash bags, a white bag inside a larger black bag, containing discarded items, on the floor of the closet in Individual #1's bedroom. | Clean and sanitary conditions shall be maintained in the home. | Who is responsible for fixing the problem and monitoring the compliance: House managers and managers.
What action that person will take: House managers are in place to make sure that all shift responsibilities are being completed. Making sure that all areas of the house are clean is a part of the staff daily shift responsibilities. The two black bags contained the individual's personal items that he chose to keep in black garbage bags. |
08/18/2023
| Implemented |
| 6400.67(a) | A two-foot by two-foot drop ceiling tile with multiple spots of water damage has been removed from the ceiling and is next to the toilet in the bathroom in the basement of the home. The floor of the basement of the home has several areas where the flooring material is missing and unfinished leaving an uneven surface posing a tripping and falling hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | Who is responsible for fixing the problem and monitoring the compliance: Director, Manager of operations
What action that person will take: We have contacted a contractor to have items fixed. The contractor was able to fix the flooring but we will have to call another contractor to address the leak above the ceiling tile.
When that action will happen: 7/26/23, 8/30/23(for the contractor to give us a quote on the leak above the ceiling tile) |
07/26/2023
| Not Implemented |
| 6400.67(b) | At 12:09PM a portion of the baseboard has been removed from the closet in Individual #1's bedroom, leaving a screw protruding approximately an inch from the bottom of the wall, posing a laceration and puncture hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Who is responsible for fixing the problem and monitoring the compliance: Director, manager of operations
What action that person will take: Screw has been removed on 7/26 |
07/26/2023
| Accepted |
| 6400.72(a) | The screen, in the window in the vacant bedroom, does not securely fit the window. [Repeat Violation, 12/22/2022, 4/20/2023] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Who is responsible for fixing the problem and monitoring the compliance: CEO/CFO
What action that person will take: Contractor had to order a custom screen. Waiting for it to arrive so he can install. |
08/01/2023
| Implemented |
| 6400.114(b) | At 11:42AM, there was an inordinate amount of ash marks on the exterior wall next to the front door of the home and the side wall of the enclosed porch from what appears to be the walls being used to extinguish smoking products. The provider's written smoking policy reads, "staff or visitors who smoke are to remain in the designated smoking area at all times. Staff or visitors are to properly dispose of all cigarette butts in a receptacle with lid." [Repeat Violation, 12/22/2022, 4/20/2023] | Written smoking safety procedures shall be followed. | Who is responsible for fixing the problem and monitoring the compliance: House managers/Managers/Supervisors/Program Specialist
What action that person will take: Next to the front door as well as rear exterior sliding glass door are designated smoke areas. Staff have been trained not to allow individual to use side wall to put cigarettes out. |
07/03/2023
| Not Implemented |
| 6400.166(a)(11) | Individual #1's June 2023 Medication Administration Record does not include the diagnosis or purpose for Doxycline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Who is responsible for fixing the problem and monitoring the compliance: Program Specialists/Director
What action that person will take: Program Specialists has put the purpose for the medication on the MAR. |
07/26/2023
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Hydroxyzine Pam with instructions to, "take 1 capsule by mouth once daily as needed for anxiety." The CEO or CEO designee did not authorize the administration of the medication. The medication was administered at 8:00PM on 6/9/2023 and at 10:30AM on 6/29/2023. [Repeat Violation, 4/20/2023] | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Who is responsible for fixing the problem and monitoring the compliance: Director, Program specialist
What action that person will take: We created a psychiatric prn policy.
When that action will happen: 7/5/23 |
07/05/2023
| Implemented |
|
|
|
SIN-00223338
|
Unannounced Monitoring
|
04/20/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The lights in Bedroom #2 flicker on and off when turned on. These are the only source of lighting in this room. [Repeat Violation, 12/22/2022] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Manager of Operations is responsible for fixing the problem. Monitoring the compliance is done by Supervisors and Managers on a daily basis. Contacted property manager on 4/25. They acknowledged the phone call. Electrician was able to resolve the switch issue on 5/18 by tightening wires connected to switch. May 10, 2023 is when the electrician is scheduled to arrive to assess. |
06/08/2023
| Implemented |
| 6400.67(b) | At 10:57AM on 4/20/2023, four vinyl floor tiles in the laundry room are unsecured and slide back and forth posing a tripping and falling slipping hazard. The cabinet in the kitchen is broken off with jagged pieces of wood still attached to the cabinet posing a laceration hazard. There is a circular hole approximately four inches in diameter containing water on the basement floor exposing an uncovered pipe posing a tripping and falling hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Manager of Operations is responsible for fixing the problem. Monitoring the compliance is done by Supervisors and Managers on a daily basis. We have contacted the property manager on 4/27/2023 about the vinyl floors, the cabinets in the kitchen and the circular hole on the basement floor. Property manager let us know that he will send out a contractor to give a quote on the task requested. ¿ When that action will happen: 5/12/2023 the contractor will come to assess and give a quote for fixing the items. 5/18, approval to remove tile was granted. Contractor will be out to remove 6/1 |
06/01/2023
| Not Implemented |
| 6400.72(a) | The screen in the window in the second floor hallway is one half inch smaller than window leaving a gap between the window and the screen. The screen in the window in Bedroom #3, does not securely fit the window leaving a gap between the window and the screen. [Repeat Violation, 12/22/2022] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Monitoring the compliance is done by Supervisors and Managers on a daily basis. : We have contacted the property manager on 4/27/2023 about the screens since they are non-standard size. Property manager let us know that he will send out a contractor to give a quote on the task requested. 5/12/2023 the contractor will come to assess and give a quote for fixing the items. The screen is a custom quote so measurements were taken and Victory Health Inc maintenance teams are currently waiting for it arrive. |
05/15/2023
| Not Implemented |
| 6400.73(a) | The three exterior steps leading from the driveway to the back yard of the home do not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Manager of Operations is responsible for fixing the problem. Monitoring the compliance is done by Supervisors and Managers on a daily basis. We contacted a contractor on 4/21/23 he came out and gave a quote on 4/28/23. The contractor then came back out on 5/2/23 and completed the handrail. 5/2/23 is when it was resolved |
05/15/2023
| Not Implemented |
| 6400.74 | There is not nonskid surfaces on the 15 wooden interior stairs leading to the second floor of the home. | Interior stairs and outside steps shall have a nonskid surface.
| Monitoring the compliance is done by Supervisors and Managers on a daily basis. We contacted a contractor on 4/21/23 he came out and gave a quote on 4/28/23. The contractor then came back out on 5/2/23 and completed the anti-skid strips on steps from first floor to second floor. |
05/15/2023
| Implemented |
| 6400.105 | The dryer vent exhaust hose is not properly secured to the window. The hose is partially attached to the window with duct tape allowing clumps of dryer lint to fall out onto the window ledge and the dryer. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Manager of Operations, Supervisors and Managers are responsible to prevent. We have contacted the property manager on 4/27/2023 about the exhaust hose not being properly secured to the window. The property manager let us know that he will send out a contractor to give a quote on the task requested. : 5/9/2023 the contractor will come to assess and give a quote for fixing the items. 5/20/2023, hired a new contractor to fix due to previous contractor is no longer available. |
06/09/2023
| Implemented |
| 6400.114(b) | The provider's written smoking policy states, "staff or visitors are to properly dispose of all cigarette butts in a receptacle with lid." At 10:32AM on 4/20/2023, there were an inordinate amount of cigarette butts on the ground near the back porch and fence and in the mulch. | Written smoking safety procedures shall be followed. | Director and Program Specialist. Purchasing cigarette disposals for homes that need them. 4/28/2023 is when it was resolved. |
04/28/2023
| Not Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Hydroxyzine Pam with instructions to, "take 1 capsule by mouth once daily as needed for anxiety." There are not written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication, and the CEO or CEO designee did not authorize the administration of the medication. The medication was administered at 8:00PM on 4/5/2023 and at 8:00PM on 4/9/2023. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Director and Program Specialist. Contact psychiatrist to request instructions of when to administer the medication. Program Specialist called the Doctor on 4/21/23 to request specific instructions on when to administer the medication the doctor said he would provide the instructions. Program Specialist followed back up with the doctor on 4/28/23 and got no response. We left a voicemail. As of 5/2/23 the doctor has yet to send instructions for this medication. When we get the instructions for this medication, we will train all med passers in the house on the update. |
05/10/2023
| Not Implemented |
|
|
|
SIN-00216885
|
Renewal
|
12/20/2022
|
Non Compliant - Finalized
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | At 1:49PM on 12/21/2022, there was a trash receptacle, containing full bags of trash, without a lid. In addition, in the driveway of home near a plastic shed, there was multitude of discarded items to include but not limited to several large plastic bags of trash, a toilet, various sizes of pipes, approximately 8 to 10 large pieces of wall board, 2 to 3 pieces of door trim boards with protruding nails, a tire and other various discarded construction materials. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | There has been major home renovation done in basement by owner. On 12/22/2022, A Mar/Manager of Operations let construction contractors know they need to discard items daily |
01/01/2023
| Not Accepted |
| 6400.65 | The bathroom in the basement of the home did not have mechanical ventilation or a window. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| On 12/22/2022, A Mar/Manager of Operations let owner of home they need a contractor to fix the issue. Owner stated he would send someone out to assess the issue on 1/4/2023 |
03/15/2023
| Not Accepted |
| 6400.66 | There is not a source of outside light at the exit at the side of the home. The outside light at the exit in the front of the home is inoperable. There is not another source of light in these areas. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1/16/2023, A Mart/Manager of Operation had contractor come out to give estimate on how to resolve. Solar powered lighting was ordered. |
01/25/2023
| Not Accepted |
| 6400.72(a) | The right side of the window in Individual #1's bedroom does not have a screen. [Repeat Violation, 6/28/2022] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 1/16/2023, A Mart/Manager of Operation had contractor come out to give estimate on how to resolve. Solar powered lighting was ordered. |
03/08/2023
| Not Accepted |
| 6400.72(b) | The screen, at the sliding glass door at the exit on the side of the home, has two holes, approximately three inches in diameter. The screen, in the window along the hallway on the second floor of the home, does not fit the size of the window by approximately one inch. [Repeat Violation, 6/28/2022, 9/2/2022, 11/9/2022] | Screens, windows and doors shall be in good repair. | Screens that show wear according to regulation will be replaced.
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03/08/2023
| Not Accepted |
| 6400.80(b) | There is an approximately six feet high by five feet wide plant with multiple long branches with thorns that appears to be a dormant rose bush, posing a puncture and laceration risk, along with obstructing the egress from the outside steps, the walkway and the fence gate at the side of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 12/22/2022, A Mar/Manager of Operations let landscaper know of the removal. |
03/04/2023
| Not Accepted |
| 6400.101 | There is a hook and eye locking mechanism on the porch door in the front of the home posing an obstructed egress when engaged. [Repeat Violation, 9/2/2022] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1/3/2023, all deadbolts and turn locks have been removed from the doors by A Mar/Manager of Operations
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01/16/2023
| Not Accepted |
| 6400.106 | The furnace was inspection on 7/6/22; however, the furnace was not cleaned. [Repeat Violation, 6/28/2022] | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| 1/14/2023. the maintenance vendor agreed to finish the tasks related to cleaning
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03/02/2023
| Not Accepted |
| 6400.110(e) | The home has three stories. At 2:53PM on 12/23/22, the smoke detectors on each of the three floors of the home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | On 12/22/2022, A Mar/Manager of Operations let owner of home they need a contractor to fix the issue. Owner stated he would send someone out to assess the issue on 1/4/2023. |
03/24/2023
| Not Accepted |
| 6400.113(a) | The fire safety instruction provided to Individual #1 on 8/2/22 did not include the home's evacuation procedures and the home's designated meeting place. | 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. | Documentation was lost on initial fire safety instructions, so it was done again by An Mar/Director
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12/22/2022
| Not Accepted |
| 6400.141(c)(3) | Individual #1's most recent Tdap vaccination was on 1/20/09. [Repeat Violation, 6/28/2022] | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Updated docs were retrieved by Da Bar/P.S. |
02/15/2023
| Not Accepted |
| 6400.142(f) | Individual #1 does not have a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual refuses to go to dentist. Staff continue to try to talk to him about importance of dentist. |
02/28/2023
| Not Accepted |
| 6400.171 | At 2:00PM on 12/21/2022, a partially used, unsealed package of hot dogs was in the refrigerator in the kitchen of the home. [Repeat Violation, 9/2/2022, 11/9/2022] | Food shall be protected from contamination while being stored, prepared, transported and served.
| 12/22/2022, the bag was placed into sealed bag and dated by Er Gar/Supervisor.
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12/22/2022
| Not Accepted |
| 6400.165(g) | The psychiatric medication review for Individual #1, completed on 9/16/22 did not include the necessary dosage of the medication(s), reason for prescribing, or the need to continue. The psychiatric medication review for Individual #1, completed 12/19/22 did not include a reason for prescribing the medications. | 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. | 12/24/2022, Reason for prescribing field was added to form. An Mar/Director trained House Managers on this new field |
02/24/2023
| Not Accepted |
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SIN-00207996
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Renewal
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06/28/2022
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Compliant - Finalized
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