Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00255986 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 11/6/2024, at 12:41 PM, the swing door located on the detached garage did not have an operable light or any other sufficient lighting source nearby [Repeat violation 11/28/23, et. al.].Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A flood light was installed outside of the garage's side door on 11/13/24 (Attachment A. 20). 11/13/2024 Implemented
6400.72(a)On 11/6/2024, at 12:46 PM, the window located in the dining room facing the backyard did not have a screen that was secure. The screen did not fully fit its opening, leaving a ten-inch-by-three-foot gap above the under-size screen that is currently installed [Repeat violation 11/28/23, et. al.]Windows, including windows in doors, shall be securely screened when windows or doors are open. On 11/13/2024, a new screen to fit the entire window was securely installed (Attachment A. 18). 11/13/2024 Implemented
6400.72(c)On 11/26/2024, at 12:45 PM, the exterior screen door located on the sunroom in the backyard did not have an operable lock. Outside doors shall have operable locks.On 11/13/24, the patio door was removed from the back porch (Attachment A. 16) 11/13/2024 Implemented
6400.80(b)On 11/6/2024, at 12:40 PM, the upper lateral portion and right vertical side of the swing door's wooden frame on the detached garage were soft, cracked, splintered, and covered completely in a black substance that appeared to be mold. The lateral portion as well as both the left and right sides of the wooden framing around the vertical-opening door of the detached garage were soft, cracked, splintered, and covered completely in a black substance that appeared to be mold. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.On 11/15/24, the landlord replaced the framing surrounding the swing door and main door on the home's garage (attachment A. 19). 11/15/2024 Implemented
6400.32(r)(1)On 11/6/2024, at 12:50 PM, Individual #1's bedroom door was equipped with a key lock on its entry side. However, Individual #1 does not have possession of a key or entry mechanism to lock and unlock the door. On 11/6/2024, at 12:51 PM, Individual #2's bedroom door was equipped with a key lock on its entry side. However, Individual #2 does not have possession of a key or entry mechanism to lock and unlock the door, as they corroborated in an interview conducted at 12:51 PM.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.On 11/25/24, the program specialist made copies of the bedroom keys and individual #1 and individual #2 were provided a copy of the key. 11/25/2024 Implemented
SIN-00182221 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional furnace cleaning company most recently on 05/28/2020. There was not documentation of prior inspection and cleaning of the furnace; therefore, compliance could not be measured.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. Corrective Action Plan-THRIVE Program Director will now begin managing and checking THRIVEs furnace checks . This will be completed by the program director adding a reminder to his monthly calendar to have all furnaces check on a quarterly basis of every home. CEO will then follow up with the Program Director during monthly quality management meetings to ensure this is completed. [Immediately, the CEO or Designee, shall train the Program Director on the requirement that furnaces be inspected and cleaned by a professional furnace cleaning company annually, as required by 6400.106. Documentation of the training shall be kept. The Program Director shall document the aforementioned quarterly audits of furnace inspections. Documentation of monthly Quality Management meetings, to include the review of annual furnace inspections, shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] 02/11/2021 Implemented
6400.141(a)Individual #1, date of admission 07/21/20, had an initial physical examination on 08/03/20.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Corrective Action Plan-THRIVE management team/referral committee will meet prior to accepting a new individual into the program to ensure that all necessary documentation is sent from the previous provider prior to admission. This includes having a physical exam within 12 months prior to admission to THRIVE and annual thereafter. Individual will not be admitted into the program until all documents are sent from previous provider. [Immediately, the CEO, or designee, shall train all staff responsible for admissions on the requirements of individual physical examinations, to include required components and timelines, as required by 6400.141(a-d). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual physical examinations quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] 02/11/2021 Implemented
6400.141(c)(6)Individual #1, date of admission 07/21/20, had an initial Tuberculin skin testing completed on 08/05/20.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Corrective Action Plan-THRIVE management team/referral committee will meet prior to accepting a new individual into the program to ensure that all necessary documentation is sent from the previous provider prior to admission. This includes the individual having TB skin testing prior to admission and every 2 years after. Individual will not be admitted into the program until all documents are sent from previous provider. [Immediately, the CEO, or designee, shall train all staff responsible for admissions on the requirements of individual physical examinations, to include required components and timelines, as required by 6400.141(a-d). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual Tuberculin evaluations quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] 02/11/2021 Implemented
SIN-00235494 Renewal 11/28/2023 Compliant - Finalized
SIN-00215872 Renewal 12/06/2022 Compliant - Finalized