Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261977 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agencies expiration date of their certificate of compliance is 3/4/25. The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/4/24 to 1/4/25, and the self- assessment was completed 1/31/25. This exceeds the requirement. Per the Regulatory Compliance Guide (RCG) there is no grace period for this regulation.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. This reg. is important to measure the record of compliance with the chapter Sunset When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 03/06/2025 Implemented
6400.62(a)According to Individual #1's Individual Support Plan (ISP) last updated 2/25/25 Individual #1 knows the dangers of poisonous substances, but due to his history of suicidal threats and ideation, these are kept locked/where Individual #1 does not have access to them. At the time of the inspection, located in the unlocked garage leaning against the wall was an opened bag of Ultimate Blend Ice Melt and the label on the back of the bag states to seek medical attention.Poisonous materials shall be kept locked or made inaccessible to individuals. It is important to follow the individual ISP by keeping poisons away from their reach to avoid ingestion. At the time of the inspection, a bag of ice melt with warning label was found in the unlocked garage. The supervisor was unaware that the Ice melt was in the garage, the melt was placed there by the facility maintenance without her knowledge. The Ice melt was removed and relocated to the facility storage. 03/05/2025 Implemented
6400.62(c)Poisons shall be stored I the original labeled container. A clear spray bottle was found under the kitchen sink containing a clear liquid inside it with the manufacture's label Simple Green All-Purpose Cleaner, however the bottle had hand-lettered in black I three places on it "BLEACH". The liquid in the spray bottle did not appear to smell like bleach, but the staff was unable to determine what the clear liquid inside the bottle was. Agency staff thew the spray bottle out during the inspection.Poisonous materials shall be stored in their original, labeled containers. It is important that poisons are kept in original container with the original labels to avoid misused. At the time of the inspection, an unidentified liquid was found in an All-Purpose container and written on Bleach. The supervisor did not ensure to check and remind staff of the importance of keeping original containers and labels. This was corrected at the time of the licensing. 03/06/2025 Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, located on the left on 1st shelf in the cabinet above the dishwasher in the kitchen was a white plastic bowl uncovered and inside the bowl was the remains of food. The food contents inside the plastic bowl were unidentifiable, but appeared to resemble a yellow crust or scrambled eggs with hardened shredded cheese on top. Agency staff threw the plastic bowl and the contents of the food away during the inspection.Clean and sanitary conditions shall be maintained in the home. It is important to have a clean and sanitary home to avoid pests. At the time of the inspection, there was a plastic bowl of unidentified food with cheese in the kitchen cabinet. Supervisors and directors will continue to do routine checks and continue to train them about the importance of the sanitation. This was corrected at the time of the licensing. 03/05/2025 Implemented
6400.67(a)Floors, walls, ceilings, and other surfaces shall be in good repair. The bifold closet door located when you enter the home was off the track when you open and close the door. The bifold closet door located in the hallway on second level of the home outside of Individual #1's bedroom was missing the knob to the bifold door at the time of the inspection.Floors, walls, ceilings and other surfaces shall be in good repair. The home is to be in good repair, as the safety and wellbeing of the individual is important. At the time of the inspection, a closet door was off track and a knob on the 2nd floor closet was missing. The knob and track came off and the supervisor put in a maintenance request to be fixed but was not done until the inspection. Maintenance installed both the knob and replaced the track on the closet. The Pictures will be sent. 03/24/2025 Implemented
SIN-00241479 Renewal 03/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)There were no screens for the windows located in the kitchen and one screen was missing in the bedroom inhabited by Individual #1.Windows, including windows in doors, shall be securely screened when windows or doors are open. The regulation is to avoid bugs and other insects from entering the home. At the time of the inspection, the window did not have a screen. The screen has been replaced 03/26/2024 Implemented
6400.82(f)At the time of inspection the sink in the bathroom utilized by Individual #1 was not draining properly. While testing the hot water in the home the water ran and filled up the sink. The water did not drain while the inspection was conducted at the home. All bathrooms shall have a sink that is functional.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. It is important for the individual sanitation and for the sink to function well in the home. At the time of the inspection, the individual bathroom sink was clogged. The sink was repaired and the water is draining down. 03/16/2024 Implemented
6400.181(b)The Assessment was not updated to indicate that the self-medication outcome for Individual #1 was reached, and that self-medication would now be completed. The Assessment for Individual #1 dated 5/3/23 noted that Individual #1 was not self-medicating. A new or revised assessment was not completed prior to the 1/2/24 notice to the Supports Coordinator(SC) for Individual #1 to note that Individual #1 would begin self-medication on 1/1/24. Documentation to support that Individual #1 had reached their self-medication goal was part of the Individual's record and noted that independence was achieved on 12/21/23. Notice was provided to the SC but neither the assessment nor the Individual Support Plan were updated to reflect the change in status. Recommendations to revise a service or outcome in the individual plan must be proceeded by a revised assessment.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.It is important to have the individual assessment updated to include all changes and progress made. This will give supporters and medical professional ideas of support. At the time of the inspection, the individual assessment was not updated to reflect his self-administration of medications. The assessment has been updated now and a picture of the page has been sent. 04/12/2024 Implemented
6400.186The Behavioral Support Plan section of the Individual Support Plan (ISP) plan last updated date of 12/15/23 noted that "the door alarms must always be working." At time of inspection there were no door alarms on the doors and it was noted that the information regarding the door alarms was old. The ISP also contained outcomes of self-medication noted within the document. It was further noted that Individual #1 "is not self-medicating." At time of inspection Individual #1 was self-medicating with documentation that the outcome had been achieved. The home was not implementing the ISP as written at the time of inspection as revisions had not been made.The home shall implement the individual plan, including revisions.This regulation is important to keep the team informed about the progress and growth of the individual, and changes in behavior. At the time of the inspection, the individual behavior plan says door alarms must be always on and there was no door alarm. Our HRT has voted to remove the door alarm because the individual has shown no sign of elopement in the past months. 04/08/2024 Implemented
SIN-00221323 Renewal 03/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103There was a love seat/couch located in front of the sliding glass doors in the living room, creating and an obstructed egress.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. 6400.103 There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transport and an emergency shelter location. This is most important for safety and evacuation incase there is fire emergency. The exit shall not be obstructed. The individual decided to rearrange his living room setting. The individual likes to arrange his living room and make changes to the setting of his couches. 03/22/2023 Implemented