Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281010 Renewal 01/07/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)On 1/8/25 at 10:49 AM, the smoke detectors on the first floor and in the basement were not interconnected. The home has three stories.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. - Maintenance staff was notified on 1/8/25 by Residential Director regarding the non-compliant fire alarms that were in violation of Code 110(e) and were not interconnected on the first floor and basement floor. - Maintenance staff scheduled a consultation with Fire Fighter Sales and Service at 10:00 am on 1/20/26 to review current fire alarm system and examine the existing interconnected system and see if it is salvageable or a new system will be ordered and installed. 01/20/2026 Implemented
6400.141(c)(10)Individual #1's physical examination completed 11/10/25 did not address communicable disease. This section was left blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. 01/12/2026 Implemented
6400.141(c)(11)Individual #1's physical examination completed 11/10/25 did not include health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.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.- On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. 01/09/2026 Implemented
6400.32(r)(1)On 1/8/25 at 10:28 AM, Individual #1's bedroom door was equipped with a pinhole door lock. Individual #1 has not been provided a specific entry mechanism to lock and unlock Individual #1's bedroom door.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 1/8/2026, Program Supervisor discussed appropriate lock preferences with Individual #1. Individual #1 stated they wished to have a keypad lock, as he is able to remember a code to enter and lock his room as he wishes. - On 1/9/26 Residential Director discussed replacing the pinhole lock, with the requested and Code 32(r) compliant keypad lock, with Maintenance Manager. Maintenance Manager agreed to order/ purchase keypad lock and install the mechanism. Residential Director requested confirmation photo of keypad lock after installation - On 1/16/26 Maintenance Manager emailed Residential Director photo of completed request of the keypad being installed on Individual #1's bedroom and a key code established for Individual #1. 01/16/2026 Implemented
6400.165(g)Individual #1 had a review of psychiatric medications on 8/6/25 and then again on 11/18/25.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.- On 1/12/26, an in-service was held with the Program Coordinators and Program Supervisors. The Residential Director, CEO, and Clinical Director hosted the in-service. Code 165(g) was reviewed with all parties present and both the Program Coordinators and Program Supervisors signed the in-service attendance sheet verifying that Code 165(g) was reviewed, explained, and they will adhere to the policy effective immediately with scheduling quarterly psychiatric evaluations within the allotted three month (90 days) specified regulatory time-frame. 01/12/2026 Implemented
SIN-00258782 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment of this home from 1/8/2025 through 1/9/2025 which was not completed during the 3 to 6 months prior to the expiration of the Certificate of Compliance or 6 to 9 months after the previous year's inspection. Additionally, the following sections of this self-assessment were left blank and not assessed for compliance: Nine or More Individuals, Emergency Placement, Respite Care, and Semi-Independent Living.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The staff will be trained on the importance of completed self-assessments in a timely manner. *Self-Assessment Checklist 01/17/2025 Implemented
6400.72(a)On 1/15/2025 from approximately 10:41am until 11:00am, the following operable windows in the home were observed without securely fitting screens: both of the two windows in the individual bedroom closest to the front door, the right window pane in the middle bedroom, both of the two windows in the individual bedroom closest to the bathroom, the dining room window, both the left and right panes of the living room window, the large window in the basement level lounge, and the three windows in the basement level laundry room.Windows, including windows in doors, shall be securely screened when windows or doors are open. Prior to admitting individuals into the house, each window, including windows in all doors will have secured screens if the doors or windows open. 01/29/2025 Implemented
6400.72(b)On 1/15/2025 at 10:51am, a crack measuring approximately eight inches in length was observed on the left pane of the window in the main level bathroom. Screens, windows and doors shall be in good repair. The bathroom window will be replaced as soon as possible due to a crack in the left pane of the window. 01/29/2025 Implemented
6400.77(b)On 1/15/2025 at 11:04am, the first aid kit did not contain tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit at the house now contains tweezers. 01/17/2025 Implemented
6400.112(a)For the calendar year 2024, there was no documentation provided for fire drills conducted in the months of February or April. An unannounced fire drill shall be held at least once a month. The fire drills will be checked by each house supervisor/specialist every week, ensuring that one fire drill has been ran according to the fire drill schedules. 01/17/2025 Implemented
6400.112(e)The fire drills conducted during sleeping hours were completed at this home on 1/22/2024 and 10/30/2024.A fire drill shall be held during sleeping hours at least every 6 months. ) Each house will run a sleep fire drill every 6 months and be tracked with the fire drill schedules created for each house. 01/17/2025 Implemented
SIN-00149890 Renewal 02/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)An unannounced fire drill was not held in May 2018. An unannounced fire drill shall be held at least once a month. Residential Program Director reviewed the fire drill records for this residence from June 2018 until the current month and all other drills were conducted as scheduled and documented properly. The current Program Specialists will be retrained in the area of Fire Safety in accordance with the regulations with a focus on how/when to conduct an unannounced drill by March 18, 2019; the training will be completed by the Residential Program Director. All new Program Supervisors/Specialists will be trained in this area upon initial orientation by the Training Coordinator. The Residential Program Director will monitor and log all monthly fire drill reports and will request an unannounced drill be conducted, if not submitted by staff, by the 28th day of each month, starting March 1, 2019. [Fire Safety/ Fire Drill Hot Water Temperature Monitoring Procedure Training documentation for Program Specialist training on 3/14/19 submitted to the Department on 3/18/19. (AES,HSLS 3/19/18)] 03/18/2019 Implemented
SIN-00110351 Renewal 03/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the staff office in the basement of the home. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. while making house visits, Managers will make sure that every phone has a current list of all required phone numbers. Each manager will sign the House Visit Log verifying that all phones are correctly labeled. This will be completed by May 1. After May 1, Managers will verify on their House Visit Log monthly that all phones are correctly labeled.[Immediately, the house manager shall put the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center on or by the telephone in the staff office in the basement of the home. Immediately, and at least quarterly a designated staff person shall complete an onsite check of all telephones in all community homes with an outside line to ensure the required telephone numbers on or by it and are legible. In addition, all staff person working in community homes shall be instructed to ensure the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line throughout the course of their daily duties and to replace or follow up with managers as needed. (AS 4/21/17)] 03/26/2017 Implemented
SIN-00061482 Renewal 03/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)A 3-Month Review for Individual #1 was not done for the period between 9-23-13 and 12-22-13. (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. in December 2013 we hired a new Supervisor of the program coordinators, who will assure that all regulatory requirements are complied with. the Supervisor will send an email to the coordinators, by the 15th of each month, reminding them of the 3 month reviews due the following month. [Staff persons were educated on the requirement on 5/7/149CHG 6/6/14)] 04/01/2014 Implemented
SIN-00201574 Renewal 03/08/2022 Compliant - Finalized
SIN-00185631 Renewal 03/30/2021 Compliant - Finalized