Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260609 Renewal 02/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At the time of the inspection, the water temperature in the downstairs bathroom was 126 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. This site location is an apartment complex where we rent one of the apartments. Sunset does not have access to the building's water supply. Sunset will send a letter to the landlord that provides the 6400.68b requirements in efforts to have them maintain a safe temperature to prevent our individuals from accidental scalding. 04/01/2025 Implemented
SIN-00253550 Unannounced Monitoring 08/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Pink Liquid in an unlabeled spray bottle was found under the kitchen sink.Poisonous materials shall be stored in their original, labeled containers. The pink liquid was thrown away during the time of the inspection. 09/05/2024 Implemented
6400.64(a)Staff # 2 reported that Individual # 1 often leaves opened food wrappers and uneaten food around the home such as under her bed and in the closet area. Staff are to be completing weekly cleanings of the home to ensure that there is no risk of infestation. On 08/11/24, Individual # 1 was placed into a temporary home due to reports of seeing mouse in the home. Staff # 3 provided photograph evidence of mouse droppings on a table, opened food wrappers found in a bin and in the closet when the home was cleaned between 08/11/24 and 08/16/24. Clean and Sanitary conditions were not maintained within the home.Clean and sanitary conditions shall be maintained in the home. The home was cleaned on 8/16/2024 by members of administration. This cleaning also included sealing all interior and exterior holes in the home to ensure that rodents can not access the living areas of the home. 08/16/2024 Implemented
6400.67(b)The carpet in the living room by the table is pulling up and created a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The carpet was replaced on the day of the inspection which was September 5, 2024. 09/05/2024 Implemented
6400.71The phone in the kitchen area did not include emergency numbers on or by the telephoneTelephone 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. An emergency phone sticker was placed on the phone on the day of the inspection on September 5, 2024. 09/05/2024 Implemented
6400.74The wooden step on the back porch did not have a non-skid surface.Interior stairs and outside steps shall have a nonskid surface. Non-slip treads were put on the wooden step on the day of the inspection which was on September 5, 2024. 09/05/2024 Implemented
6400.113(a)Individual # 1 was placed into an emergency placement home from 08/11-16/24. Individual # 1 was not trained in Fire Safety upon admission to the emergency home to ensure safety if a fire occurred. 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. Sunset will make the following changes to Sunsets Policies and Procedures: Any time that a site closure is needed to be completed by Sunsets point person, and an individuals staffing crisis plan in the ISP needs to be implemented, the point person will contact Sunsets Agency Trainer, or who she allows to train on her behalf, who will complete individual fire safety with the individual who has been temporarily relocated. This will ensure that the individual know the necessary procedures to take in the event of an emergency. 11/15/2024 Implemented
6400.142(a)Individual # 1 had a dental examination on 09/27/22 and not again until 01/20/24. Delays for appointment were due to insurance reasons and one refusal by Individual # 1.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Sunsets CEO of Residential Services trained Sunsets Medical Coordinator that Sunset should have kept prior appointment where the individual needed to pay out of pocket and then switch to another provider once to ensure compliance with the regulations. This is vital to ensuring that the individual receives the necessary dental care to prevent illness and serious health conditions. 11/15/2024 Implemented
6400.144Individual # 1's assessment dated 01/17/24 reads "it is recommended by her physician to stick to 45 grams of carbs per meal···" On 06.27.24, Individual # 1 ate 73 g of carbs during breakfast. On 06/26/24, Individual # 1 ate 81 g of carbs for lunch. On 06.28.24 Individual # 1 ate 51 g carbs for dinner. Individual # 1 ate 58 g of carbs on 08.05.24 for lunch and 54 g carbs for dinner. Individual # 1 ate over 45 grams of carbs per meal on the following days in August 2024: 1st-16th, 18th-30th.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Sunset is creating menus for each individual based on their food preferences. These menus will be tailored to each individuals dietary restriction. On the top of Sunsets Food Diary page for each individual, it will list the individuals' dietary restrictions. This will ensure that each staff know the dietary restrictions and can better educate the individual when they are not following their dietary restrictions. The Food Diary also have a designated area where staff will check if the individual refused what was on their menu and a reminder to the staff to educate the individual on the importance of making healthy choices. This protects the individual health and safety by ensuring the provision of appropriate medical services. 11/15/2024 Implemented
6400.186Individual # 1's ISP dated 07/22/24 reads, "Individual # 1 has the right to keep a messy room, however, if Individual # 1's room poses a health hazard, can attract rodents or other infestations, or can be viewed as a fire concern, staff are required to clean the room only to the point that it does not pose any of the above hazards." Individual # 1's ISP was not implemented as Individual # 1 needed to be relocated to another home due to a rodent infestation. This was due to opened food wrappers being found around the home by agency staff upon the emergency placement cleaning of the home.The home shall implement the individual plan, including revisions.The home was cleaned on 8/16/2024 by members of administration. 08/16/2024 Implemented
SIN-00199198 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a screw, approximately 3 inches long, protruding from the dining room chair leg that was bolted to the floor on the left side of the table. Furniture and equipment shall be nonhazardous, clean and sturdy. Issue was corrected immediately by maintenance. 03/08/2022 Implemented
6400.112(e)The home at conducted a sleeping fire drill on 1/19/2021. The staff attempted to complete another sleeping drill several times in the month of May, but the individual refused. May was only 4 months from the last completed sleep drill. The agency could have attempted another sleep drill in both June and July in order to be in compliance with this regulation; however, another sleep drill was not attempted until September of 2021, which exceeds the 6-month requirement.A fire drill shall be held during sleeping hours at least every 6 months. Policies and procedures were updated: If an individual refuses a night fire drill, drills will continue weekly until the individual successfully completes a night fire drill. 03/08/2022 Implemented
6400.141(c)(4)Individual # 1 did not receive a hearing screening during most recent physical completed on 02/09/22. Hearing screenings are required annually.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Annual hearing exam was schedule for 02/25/2022 however was rescheduled for 4/27/2022 due to bad weather on 2/25/2022. 03/08/2022 Implemented
6400.145(2)Transportation to be used in case of an emergency is unclear. It states, "Staff will follow or meet emergency staff at my preferred hospital".The home shall have a written emergency medical plan listing the following: The method of transportation to be used. All individuals Emergency Medical plans were updated with person-specific information that includes the preferences of the individual (guardian) and how they will be transported to their preferred hospital in the event of an emergency. 03/08/2022 Implemented
6400.145(3)All of the homes had an emergency medical plan that did not specify what the staffing plan was in the event of an emergency.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.All individuals Emergency Medical plans were updated with person-specific information that includes the preferences of the individual (guardian) and what the staffing ratios will be, additional staffing if needed, in the case of an emergency. 03/02/2022 Implemented
6400.171There were glass bottles of sauce stored in the locked office that were opened and the instructions on the bottle state, "refrigerate after opening". If items need to be locked up for the safety of the individual, then a mini fridge should be purchased and put in the locked office so that the food can be stored properly.Food shall be protected from contamination while being stored, prepared, transported and served. A mini-fridge was purchased and placed in the office. 03/08/2022 Implemented
6400.182(a)- Individual # 1's ISP plan last updated on 02/04/22 identifies a target date as November 26, 2020 for a less restrictive behavior support plan to be developed. The ISP reads "A less restrictive behavior support plan can be developed if individual can refrain from displaying negative behaviors which may cause physical harm to self or others···Target date is November 26, 2020." Plan was not revised to reflect new target dates.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.Track changes were sent to the SC on 3/7/2022 to have Behavior Support section updated. 03/08/2022 Implemented
SIN-00194982 Unannounced Monitoring 10/22/2021 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There were numerous drawers in the kitchen and bathroom that were removed and not present.Floors, walls, ceilings and other surfaces shall be in good repair. The drawers were screwed shut so they can't be used as weapons. All items in drawers will be stored neatly in the basement. 11/02/2021 Accepted
6400.71The telephone located in the home did not have the emergency numbers on it or nearby.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. Phone stickers were placed on phones. 11/02/2021 Accepted
6400.81(j)Individual #1's bed is located in the living room of the home. There is no door for Individual #1 to pull shut for privacy. A bedroom shall have doors at all entrances for privacy.After having an ISP team meeting, Sunset will be requesting a waiver to allow her to remain in her living room. 11/02/2021 Accepted
6400.81(k)(6)Individual #1 did not have a mirror available in their bedroom.In bedrooms, each individual shall have the following: A mirror. A bon=breakable mirror has been placed in her room. 11/02/2021 Accepted
6400.111(c)At the time of the virtual walkthrough on 10/22/21, there was no fire extinguisher available in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Sunset has reached out to the SC to add that that fire extinguishers are to be locked up in the home due to safety concerns. HRT have approved the modified BSP to include keeping fire extinguisher locked up. 11/02/2021 Accepted
SIN-00168050 Renewal 02/19/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment was not completed 3 to 6 months prior to expiration of certification or 3 to 6 months following the last inspection.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. Self-assessment will be completed by the CEO (or who he delegates it to) 3-6 months prior to the expiration of the license. 02/24/2020 Implemented
SIN-00150195 Renewal 02/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)Outside walkways- there was ice and snow approx. 3 inches deep on the walkway leading to the front door. The driveway was also covered in ice, making walking difficult. Outside walkways shall be free from ice, snow, obstructions and other hazards. House Manager will conduct daily walk through along with the Maintenance Department to ensure all exits are clear of ice/snow or any other debris. 03/01/2019 Implemented
6400.101Obstructed egress- the exit leading to the front door of the home that is used for a fire drill exit was blocked with 3-4 inches of ice and snow.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. House Manager will conduct daily walk through along with the Maintenance Department to ensure all exits are clear of ice/snow or any other debris. 03/01/2019 Implemented
6400.151(a)Staff#1's Date of hire was 10/23/18, the physical was not completed until 10/31/18 & staff #2 DOH was 11/20/18 and physical was not completed until 11/30/18. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. 03/01/2019 Implemented
Article X.1007The criminal background checks where not completed 5 days before date of hire for staff #1 & staff #2. Staff 1 DOH- 10/23/18- criminal check not completed until 10/23/18. Staff #2'sDOH 11/20/18, criminal background was checked 11/20/18.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. 03/01/2019 Implemented