Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292212 Renewal 07/22/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The May 2026 Fire Drill record did not indicate whether the fire alarm or smoke detector was operative.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. Review a standardized fire drill record form that includes fields for Address, date, time, evacuation time, exit route used, problems encountered, and fire alarm/smoke detector status. Train all staff on the updated fire drill documentation procedures by 8/5/2026. Conduct a review of past fire drill records and update missing information where possible. 08/27/2026 Implemented
SIN-00253824 Renewal 08/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Individual number one is prescribed Gunafacine 1mg tab (take ½ tablet by mouth 3 times a day 8am, 4pm, 8pm). On 8/8/24 at 4pm, staff initials (#1) appear on the MAR indicating that the medication was administered at that time. However, the medication remains in the blister pack for that administration time. On that date, the individual was hospitalized. In discussion with the staff, they were aware that the medication at that time was not administered, and recognized this was a documentation error and it should have been appropriately documented as such and indicated on the back of the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The odp medication certified trainer retrained direct support professional , in discussion with staff we were made aware that the medication at the time was not administered and recognized this was a documentation error and it should have been appropriately documented as such and indicated on the back of the MAR 09/27/2024 Implemented
SIN-00210375 Renewal 08/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The railing on the stairs between the first and second floor did not extend all the way up to the second floor. After the inspection, the agency provided a photo showing an additional railing had been installed on the portion of the stairway that had none previously. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. correction was completed before inspector left site 08/31/2022 Implemented
SIN-00271324 Renewal 08/14/2025 Compliant - Finalized
SIN-00192232 Renewal 08/31/2021 Compliant - Finalized
SIN-00175125 Renewal 08/18/2020 Compliant - Finalized