Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00273455 Unannounced Monitoring 09/02/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's assessment, completed 3/25/2025, states that Individual #1 is not financially independent. Individual #1's service plan, last updated 7/31/2025, reads, "[Individual #1] is unable to independently manage [their] finances. When [Individual #1] is given money, [they] will quickly spend it and then becomes frustrated when [Individual #1] does not have money later to spend." The provider agency is not keeping a ledger of personal possessions and funds received by or deposited with the individual. [Repeat Violation, 12/22/2022]The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Actions Taken to Resolve the Issue: The team reassessed Individual #1 and determined he is financially fit to manage his own finances. Individual #1 is able to identify priorities in money spending, understands the importance of bills being paid, and recognizes that his Rep Payee manages those responsibilities on his behalf. He receives a weekly allowance, reinforcing his understanding that bills are paid first. On 9/12/25, the provider reviewed Individual #1's ISP and contacted his Support Coordinator to update the ISP to reflect Individual #1's true financial capabilities. Responsibility & Compliance Monitoring: The Program Specialist will ensure that assessments accurately reflect each individual's financial independence. Coordination with Support Coordinators will be conducted immediately whenever discrepancies between the assessment and ISP are identified. 09/15/2025 Implemented
6400.22(d)(2)Individual #1's assessment, completed 3/25/2025, states that Individual #1 is not financially independent. Individual #1's service plan, last updated 7/31/2025, reads, "[Individual #1] is unable to independently manage [their] finances. When [Individual #1] is given money, [they] will quickly spend it and then becomes frustrated when [Individual #1] does not have money later to spend." The provider agency is not maintaining a financial ledger of personal disbursements made to or for Individual #1.(2) Disbursements made to or for the individual. Actions Taken to Resolve the Issue: The team reassessed Individual #1 and determined he is financially fit to manage his own finances. Individual #1 is able to identify priorities in money spending, understands the importance of bills being paid, and recognizes that his Rep Payee manages those responsibilities on his behalf. He receives a weekly allowance, reinforcing his understanding that bills are paid first. On 9/12/25, the provider reviewed Individual #1's ISP and contacted his Support Coordinator to update the ISP to reflect Individual #1's true financial capabilities. Responsibility & Compliance Monitoring: The Program Specialist will ensure that assessments accurately reflect each individual's financial independence. Coordination with Support Coordinators will be conducted immediately whenever discrepancies between the assessment and ISP are identified. 09/15/2025 Implemented
6400.64(a)At 12:49PM, The interior left basin of the laundry tub located in the home's basement was soiled in several areas throughout with a grayish substance of fabric, lint, dust, debris, and other particles.Clean and sanitary conditions shall be maintained in the home. Actions Taken to Resolve the Issue: On 9/2/2025, staff sealed the partially used bacon and all other unsealed food items, and a pillowcase was placed on the uncovered pillow. On 9/9/2025, mattresses were replaced where needed, and deep cleanings were completed at affected properties (laundry tub, attic fan, bedroom A/C and windowsill, garage floor, and basement baseboards). Dead insects were removed during the deep cleaning. Responsibility & Compliance Monitoring: House Managers and Direct Support Staff at each property are responsible for daily cleaning and ensuring proper food storage. Supervisors will conduct home inspections twice weekly at each property to confirm cleaning, food storage, and general household maintenance. 09/02/2025 Not Implemented
6400.67(a)At 12:34PM, there was an exposed one-quarter inch gap between the two wall panel boards on the left side of Individual #1's bed. At 12:37 PM, there was an irregular-shaped hole, measuring approximately three-inches by five-inches in area, and a linear indentation, measuring approximately seven-inches in length, on the wall adjacent to Individual #1's bedroom door. At 12:44 PM, there was a circular hole, measuring three-inches in diameter, on the wall behind Individual #1's bedroom door.Floors, walls, ceilings and other surfaces shall be in good repair. he holes in Individual #1's bedroom wall were originally scheduled for repair on 8/27/2025, but the contractor was delayed waiting for materials. The patching was completed on 9/3/2025. All other identified maintenance issues---including wall repairs, outlet cover replacement, radiator vent cover reattachments, dresser track repair, and basement ceiling tile replacement---were completed by the licensed contractor on 9/16/2025. Electrical work was completed to ensure that the smoke detectors in the three-story home were properly interconnected. All hazards were corrected at their respective homes. Responsibility & Compliance Monitoring: Supervisors will oversee contractor work orders to ensure timely and complete repairs. Program Specialist will review monthly Quality Assurance (QA) checklists to confirm maintenance-related violations are not recurring. Supervisors will verify smoke detector interconnection during twice-weekly home inspections. 09/16/2025 Implemented
6400.67(b)At 12:32PM, the outlet cover located to the left side of the small microwave on the kitchen counter was broken and missing a piece on its lower left corner, exposing sharp, plastic edges. Floors, walls, ceilings and other surfaces shall be free of hazards.Actions Taken to Resolve the Issue: The holes in Individual #1's bedroom wall were originally scheduled for repair on 8/27/2025, but the contractor was delayed waiting for materials. The patching was completed on 9/3/2025. All other identified maintenance issues---including wall repairs, outlet cover replacement, radiator vent cover reattachments, dresser track repair, and basement ceiling tile replacement---were completed by the licensed contractor on 9/16/2025. Electrical work was completed to ensure that the smoke detectors in the three-story home were properly interconnected. All hazards were corrected at their respective homes. Responsibility & Compliance Monitoring: Supervisors will oversee contractor work orders to ensure timely and complete repairs. Program Specialist will review monthly Quality Assurance (QA) checklists to confirm maintenance-related violations are not recurring. Supervisors will verify smoke detector interconnection during twice-weekly home inspections. 09/16/2025 Implemented
6400.76(a)At 12:39PM, the interior framing track to the left drawer of the dresser in Individual #1's bedroom was broken and did not provide stability, as the drawer tilted downward when it was retracted or opened. Furniture and equipment shall be nonhazardous, clean and sturdy. Actions Taken to Resolve the Issue: The holes in Individual #1's bedroom wall were originally scheduled for repair on 8/27/2025, but the contractor was delayed waiting for materials. The patching was completed on 9/3/2025. All other identified maintenance issues---including wall repairs, outlet cover replacement, radiator vent cover reattachments, dresser track repair, and basement ceiling tile replacement---were completed by the licensed contractor on 9/16/2025. Electrical work was completed to ensure that the smoke detectors in the three-story home were properly interconnected. All hazards were corrected at their respective homes. Responsibility & Compliance Monitoring: Supervisors will oversee contractor work orders to ensure timely and complete repairs. Program Specialist will review monthly Quality Assurance (QA) checklists to confirm maintenance-related violations are not recurring. Supervisors will verify smoke detector interconnection during twice-weekly home inspections. 09/16/2025 Implemented
6400.81(k)(2)At 12:30PM, there was a permanent indentation in the center of the mattress in Individual #1's bedroom, measuring approximately one-foot, one-half inches by six inches, and depressed at a depth of six inches from the rest of mattress' outer surface. [Repeat Violation, 6/29/2023]In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Actions Taken to Resolve the Issue: On 9/2/2025, staff sealed the partially used bacon and all other unsealed food items, and a pillowcase was placed on the uncovered pillow. On 9/9/2025, mattresses were replaced where needed, and deep cleanings were completed at affected properties (laundry tub, attic fan, bedroom A/C and windowsill, garage floor, and basement baseboards). Dead insects were removed during the deep cleaning. Responsibility & Compliance Monitoring: House Managers and Direct Support Staff at each property are responsible for daily cleaning and ensuring proper food storage. Supervisors will conduct home inspections twice weekly at each property to confirm cleaning, food storage, and general household maintenance. 09/09/2025 Implemented
6400.81(k)(3)At 12:35PM, there was a pillow with no pillowcase on the bed in Individual #1's bedroom on the second floor of the home. [Repeat Violation, 6/29/2023]In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.Actions Taken to Resolve the Issue: On 9/2/2025, staff sealed the partially used bacon and all other unsealed food items, and a pillowcase was placed on the uncovered pillow. On 9/9/2025, mattresses were replaced where needed, and deep cleanings were completed at affected properties (laundry tub, attic fan, bedroom A/C and windowsill, garage floor, and basement baseboards). Dead insects were removed during the deep cleaning. Responsibility & Compliance Monitoring: House Managers and Direct Support Staff at each property are responsible for daily cleaning and ensuring proper food storage. Supervisors will conduct home inspections twice weekly at each property to confirm cleaning, food storage, and general household maintenance. 09/09/2025 Implemented
6400.81(k)(5)At 12:43PM, the vertical storage cabinet in Individual #1's bedroom was missing the bar used to hang clothes, and there were no alterative options provided in which to do so.In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. Actions Taken to Resolve the Issue: The missing wardrobe bar was found and installed the same day in the vertical storage cabinet. Alternative hanging options were available in a closet across the hallway, which both inspectors observed, but were not counted by the inspector since they were not inside Individual #1's room. All other maintenance issues---including wall repairs, outlet cover replacement, radiator vent cover reattachments, dresser track repair, and basement ceiling tile replacement---were completed by the licensed contractor on 9/16/2025. Electrical work was completed to ensure that the smoke detectors in the three-story home were properly interconnected. Responsibility & Compliance Monitoring: Supervisors will oversee contractor work orders to ensure timely and complete repairs, including functional bedroom storage. Program Specialist will review monthly QA checklists to confirm maintenance-related violations are not recurring. Supervisors will also verify smoke detector interconnection during twice-weekly home inspections. 09/16/2025 Implemented
6400.214(b)At 1:50PM, the most recent incident reports pertaining to Individual #1 and the most recent copy of Individual #1's Restrictive Procedure Plan was not present in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Actions Taken to Resolve the Issue: The missing incident reports and Restrictive Procedure Plan were immediately retrieved and placed in the home. Staff were reminded to ensure that all current documentation is maintained onsite and accessible at all times. Responsibility & Compliance Monitoring: Supervisors will verify the presence of all required documentation during twice-weekly home inspections. Program Specialist will review monthly QA checklists to ensure compliance with documentation requirements. 09/02/2025 Not Implemented
6400.163(g)At 12:56PM, there was a loose, white, oval shaped pill that had been removed from the blister pack at the bottom of the toolbox containing Individual #1's medications. This pill appeared to be Individual #1's prescribed medication, Ondansetron. [Repeat Violation, 12/2/2022, 10/2/2024]Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Actions Taken to Resolve the Issue: The loose pill was disposed of using VHI-approved methods: allowed to disintegrate in dirt and water, then placed in the trash. The supervisor who conducted the home inspection prior to the licensing inspection explained that the pill likely became loose while staff were returning medications to the box, possibly splitting the blister pack with a fingernail. Staff were reminded of proper medication handling procedures to ensure all pills remain in their original, labeled packaging. Training on medication safety and secure storage was reviewed with staff following the incident. Responsibility & Compliance Monitoring: Supervisors will verify medication storage and integrity during twice-weekly home inspections. Program Specialist will review monthly QA checklists to ensure proper medication handling and storage practices are consistently followed. 09/02/2025 Implemented
SIN-00260697 Unannounced Monitoring 01/31/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 1/31/2025 at 11:49AM, there was strong odor of urine that appeared to be emanating from soiled sheets on a mattress that was leaning against the wall in Individual #1's bedroom on the second floor of the home. In addition, Individual #1's clothing and other miscellaneous items were strewn about the bedroom.Clean and sanitary conditions shall be maintained in the home. We received this violation because the client continues to be embarrassed when he wets the bed and hides sheets underneath the bed or in the closet. We also were doing a room cleaning drill during the time to assess cleanliness for the bedroom area. Our immediate action was to assist the client with finding the sheets and cleaning the rest of the room. The issue was resolved 1/31/2025. Supervisors/House Managers/DSP are responsible for fixing the problem and monitor the compliance. 02/03/2025 Implemented
6400.67(b)On 1/31/2025 at 11:37AM, there was a two-inch by four-inch jagged split in the wood paneled wall in the hallway near the dining room posing a laceration hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.We received this violation due to part of the wood panel was sticking out. As a temporary solution, we toke duck tape and placed it over the area protruding on 1/31/2025. Director/PS/Supervisor/House Manager/DSP are responsible for reporting anomalies in the house to the maintenance team so the proper contractor(s) can be contacted to resolve the issue. 02/19/2025 Implemented
6400.76(a)On 1/31/2025 at 11:50AM, the box spring belonging to Individual #1 was reportedly broken and removed from the bedroom. Individual #1's mattress was leaning against the wall, the bedframe was detached from the headboard and the wooden headboard was leaning against the wall in Individual #1's bedroom on the second floor of the home. Furniture and equipment shall be nonhazardous, clean and sturdy. We received this violation because we were in the process that day of replacing the bed frame so at the time, the headboard, bedroom, and bedroom were not in a safe presentable manner that morning. We did present the inspector with receipts on when the new bed was delivered and the installation was scheduled within 24 hours. We resolved the issue the day of inspection by installing new bedroom as scheduled. Director/PS/Supervisors are responsible for fixing the problem and monitoring the compliance 02/15/2025 Implemented
6400.171On 1/31/2025 at 11:34AM, an uncovered bowl of noodles and a package of Eggo waffles with instructions to keep frozen were on the shelves in the refrigerator in the kitchen of the home. [Repeat Violation, 12/22/2022, et. el]Food shall be protected from contamination while being stored, prepared, transported and served. We received this violation because the client placed the package of waffles on the shelf after use. The uncovered bowl was not properly disposed of after use. We immediately resolved this issue by throwing out waffles and getting rid of the bowl of noodles on 1/31/2025. PS/Supervisors/House Managers/DSP are responsible for fixing the problem and monitoring the compliance 02/20/2025 Not Implemented
SIN-00254117 Unannounced Monitoring 10/02/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 1:42PM, there was a strong urine odor and soiled linens in the cabinet in Individual #1's bedroom.Clean and sanitary conditions shall be maintained in the home. We received this violation because KW hid the urinated sheets in his wardrobe because he did not want anyone to know that he wet the bed the night before. DSP, House manager are responsible for fixing the problem and monitoring the compliance. Manager, Supervisor will check and verify task are being completed. 10/10/2024 Not Implemented
6400.67(a)At 1:45PM, the front panel was broken off the top left drawer of the dresser in Individual #1's bedroom.Floors, walls, ceilings and other surfaces shall be in good repair. We received this violation because the individual removed the front panel off the dresser. We replaced the dresser. Responsibility lies on the House Manager. Managers, supervisors, and program specialists will make sure daily checks are performed everyday using specific tools. 10/06/2023 Not Implemented
6400.81(i)At 1:44PM, a towel was covering the top half of the window on the left side of the wall facing the front of the home leaving the bottom of the window uncovered with no curtains, drapes or blinds.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The individual removed the curtain from the window and replaced it with a terrible towel. The curtain was placed on top of his dresser. We spoke with KW and informed him he cannot remove the curtains or blinds from the window. Responsibility lies on the DSP to prevent this from reoccurring. House manager, manager program specialist will make sure daily checks are performed everyday using specific tools. 10/02/2024 Implemented
6400.214(b)The most recent copy of Individual #1's Individual Service Plan was not present at the home. [Repeat Violation, 12/20/2022, 4/20/2023, 6/29/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. We received this violation because the individual¿s plan was not available to be taken to the house at the beginning of the new fiscal year. Responsibility lies on the House Manager to report if the document is missing or out of date. Program Specialist and Director will verify latest version of the document. 11/01/2024 Implemented
SIN-00241194 Unannounced Monitoring 03/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 10:39AM, Individual #1 was unsupervised in his bedroom using a spray bottle of Clorox Disinfectant Cleaner to wash his bedroom walls and mattress cover. Individual #1's assessment, completed 1/5/2024, states that he cannot safely use or avoid poisons and reads, "[Individual #1] is at danger of purposely swallowing poisons." [Repeat Violation, 12/22/2022]Poisonous materials shall be kept locked or made inaccessible to individuals. We received this violation due to staff allowing individual to clean but they needed to be in viewing distance of the client. This was issue was instantly resolved after being addressed on 3/19/24 03/20/2024 Implemented
SIN-00240704 Unannounced Monitoring 02/21/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At 10:58AM, an unlabeled plastic spray bottle with "Fabuloso" hand-written on it was in a cabinet in the dining room of the home.Poisonous materials shall be stored in their original, labeled containers. Spray bottled was not labeled and was placed at the individual's home. We removed the unmarked bottle from the refrigerator while inspectors were still present in the home. The issue was resolved immediately after being noted ¿2/21/24¿ Who is responsible for fixing the problem and monitoring the compliance: Staff, house managers, Supervisors, Program specialist, Director 03/28/2024 Implemented
6400.64(f)At 10:40AM, an uncovered trash receptable with a white bag containing trash overflowing over the top, a white plastic bag containing trash on the ground and a damaged door was outside the front of the home. [Repeat Violation, 12/22/2022]Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.We received this violation because the lids were off the trash cans. We put the lids back on the trash can on 2/21/24 while the inspectors were still at the site. Who is responsible for fixing the problem and monitoring the compliance: house managers, Supervisors, Program specialist, Director 03/27/2024 Implemented
6400.171At 10:55AM, an unsealed, partially used package of Chicken Breast lunch meat was in the drawer inside the refrigerator in the kitchen of the home. [Repeat Violation, 12/22/2022]Food shall be protected from contamination while being stored, prepared, transported and served. We received this violation because the lunch meat was not fully sealed via the zip lock zip fastener. We sealed the lunch meat on 2/21/2024 Who is responsible for fixing the problem and monitoring the compliance: Staff , house managers, managers, program specialist. 03/04/2024 Implemented
6400.214(b)Individual #1's most recent incident reports were not present at the home. [Repeat Violation, 12/22/2022, 4/20/2023, 6/29/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. We received this violation due to all recent incidents not printed out. We printed out updated incident reports on 2/21/2024 Who is responsible for fixing the problem and monitoring the compliance: Managers, Program specialist, Director 03/06/2024 Implemented
6400.32(d)At 10:50AM, two signs were on the refrigerator that read, "[Individual #1's] phone must be turned in at 10pm every night. 3-11 staff is responsible for making sure that it is collected," and, "[Individual #1's] room has to be checked every 2 hours for cleanliness while on the clock." [Repeat Violation, 9/22/2023]An individual shall be treated with dignity and respect.We received this violation due to individuals printout contained personal information. We removed the sign from the refrigerator while inspectors were still present in the home on 2/21/2024. Who is responsible for fixing the problem and monitoring the compliance: Staff, house managers, Supervisors, Program specialist, Director 03/27/2024 Implemented
6400.165(b)Ondansetron was prescribed to Individual #1 on 7/17/2023. The instructions on the February 2024 Medication Administration Record read, "take 1 tablet by mouth every 8 hours or as directed." The physician's orders read, "take 1 tablet by mouth every 8 hours as needed for nausea or vomiting for up to seven days." On 2/21/2024, this medication was not administered and remained in Individual #1's medication box.A prescription order shall be kept current.We disposed of the medication on 2/21/2024. We understood the label to read as when he takes the medication he had 7 days to continue the medication. With the script being written for up to 7 days this is our discontinuation order. So we discontinued the medication that day. Who is responsible for fixing the problem and monitoring the compliance: Staff, house managers, Supervisors, Program specialist, Director 03/01/2024 Implemented
6400.165(c)On 2/7/2024, Individual #1 was prescribed Nifedipine 0.2% Ointment with instructions to, "Apply peri-annally two times daily." This medication has not been administered to Individual #1. [Repeat Violation, 12/22/2022]A prescription medication shall be administered as prescribed.We received this violation because the it was not administered. We were in communication with the individuals physician that prescribed the medication. We received clarification on how they wanted the medication prescribed 2/22/24. We reentered the medication into the MAR with the additional instructions that clarified how the physician wanted the medication administered. Who is responsible for fixing the problem and monitoring the compliance: Staff, house managers, Supervisors, Program specialist, Director 02/22/2024 Implemented
6400.165(e)On 2/13/2024, Program Manager #1 documented on Individual #1's February Medication Administration Record that Nifedipine 0.2% Ointment was discontinued. There were not written orders from the physician to discontinue the medication.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.We were in communication with the individuals physician that prescribed the medication. We received clarification on how they wanted the medication prescribed 2/22/24. We reentered the medication into the MAR with the additional instructions that clarified how the physician wanted the medication administered 03/01/2024 Implemented
6400.194(b)The Human Rights Team for the meetings held on 2/15/2023, 6/1/2023, 8/30/2023, 11/22/2023 and 2/10/2024 to discuss Individual #1's Restrictive Procedure Plan consist of Chief Executive Officer #2 and Chief Financial Officer #3 only. These employees do not have a recognized degree, certification or license relating to behavioral support.The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan.We received this violation because our HRT does not contain a member with the proper certification(s). We are revising our membership in our Human RIghts Team. We reached out to several businesses. We are waiting for them to quote and sign contract. 04/21/2024 Not Implemented
SIN-00236237 Unannounced Monitoring 11/22/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.21(b)The Agency commenced operation of this Community Home for Individuals with an Intellectual Disability or Autism on November 20, 2023, prior to the submission of an application and approval from the Department.The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued.Victory Health Inc received this violation due to an emergency move that was not approved by ODP nor was it relayed through all the proper channels in regards to the individuals team. 12/15/2023 Implemented
6400.62(a)At 11:08AM, aerosol spray cans of Easy Off Oven Cleaner, Lysol Disinfectant Spray and glass cleaner and bottles of Mr. Clean, Lysol, Orange Glo and bleach cleaner were on a shelf in an unlocked closet in the living room on the second floor of the home. [Repeat Violation, 12/22/2022]Poisonous materials shall be kept locked or made inaccessible to individuals. We received this violation because cleaners were in the closet but the lock was not locked during the time of the unannounced inspection. 11/22/2023 Not Implemented
6400.63(a)At 10:18AM, the hot water temperature measured 138.2F at the sink in the kitchen of the home. [Repeat Violation, 5/10/2023]Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. We received this violation due to multiple adjustments of the hot water tank in a new site. We turned the water temperature down until we were within optimum regulation temperatures. 11/22/2023 Implemented
6400.64(d)At 10:20AM, a white bag filled with trash was on top of a mop bucket and a cardboard box containing a white bag filled with trash and other trash were on the floor in the kitchen of the home.Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. We received this violation due to multiple items being thrown away due to move in. We had boxes/bags that were not immediately covered by move in staff. We resolved the issue within 1 hour of the unannounced inspection. 12/29/2023 Not Implemented
6400.64(f)At 10:11AM, an uncover trash receptacle containing full white trash bags was outside in front of the home. [Repeat Violation, 12/22/2022]Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.We received this violation due to multiple items being thrown away due to move in. We had boxes/bags that were not immediately covered by move in staff. We resolved the issue within 1 hour of the unannounced inspection. 12/29/2023 Not Implemented
6400.68(b)At 11:09AM, the hot water temperature measured 126.6F at the bathtub in the bathroom on the second floor of the home. [Repeat Violation, 5/10/2023] Hot water temperatures in bathtubs and showers may not exceed 120°F. We received this violation due to multiple adjustments of the hot water tank in a new site. We turned the water temperature down until we were within optimum regulation temperatures. 12/29/2023 Implemented
6400.72(b)At 11:11AM, there was four inch long tear in the screen in the window across from the doorway in the living room on the second floor of the home. [Repeat Violation, 6/29/2023, 7/25/2023] Screens, windows and doors shall be in good repair. We received this violation due to a tear in the screen. We had the screen repaired 12/29/2023 Implemented
6400.74At 11:05AM, the interior stairs, leading to the basement and to the second floor of the home, did not have a nonskid surface. [Repeat Violation, 4/20/2023]Interior stairs and outside steps shall have a nonskid surface. This issue occurred due to a scheduling conflict with our contractor to do the work. On 11.23.2023, the anti skid mats were installed 12/29/2023 Implemented
6400.76(c)At 11:10AM, the living room on the second floor of the home was furnished with only a small ottoman.Furniture shall be comfortable and home-like. We received this violation due to the fact on the move in date, the professional movers could not not fit through the front door or the side door of the home the original couch. We order a new couch that had to be built in the home to resolve this issue. 01/05/2023 Implemented
6400.77(b)At 11:15AM, the first aid kit did not contain tape. [Repeat Violation, 12/22/2022] 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. We received this violation because the thermometer¿s batteries were low. We replaced the batteries in the thermometer within 4 hours of the unannounced inspection. 12/29/2023 Implemented
6400.110(e)At 11:34AM, the smoke detector in the basement of the three story home was not interconnected with the smoke detectors on the first and second floors of the home. [Repeat Violation, 12/22/2022]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. We installed an interconnected smoke detector in the basement 12/29/2023 Implemented
6400.163(d)Individual #1's prescribed medication, Lorazepam, a controlled substance, was not double locked. At 11:21AM, a biohazard box with used pre-filled Abilify syringes was on the shelf in an unlocked closet in the living room of the home. [Repeat Violation, 4/20/2023]Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.We received this violation due to our controlled substance being in locked containment box but not locked in closet. We resolved by locking in containment item immediately in closet. 11/25/2023 Implemented
6400.166(a)(2)Individual #1's November 2023 Medication Administration Record documented an incorrect physician as the prescriber of the medications. [Repeat Violation, 12/22/2022]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.We received this violation due to incorrect information populated regarding physician. We have reviewed each individuals MAR to verify that each prescibber listed on the pharmacy label is also listed on the MAR. We have found that each prescribing will at times have a physicians assistant submit the prescription to the pharmacy which then causes the pharmacy to list that specific physicians assistant on the pharmacy label. We have written in each prescribing physicians name on the MAR. 12/29/2023 Not Implemented
6400.186Individual #1's Individual Plan, last updated 7/21/2023, states Individual #1 requires 24-hour supervision within eyesight. Staff interviews revealed that staff are not always in visual range supervision with Individual #1 and staff will conduct visual checks every so often.The home shall implement the individual plan, including revisions.We interviewed staff about concerns of not being in visually accessible to the individual. We scheduled a training regarding supervision for all staff in the home. we also hosted a training session on 12/1/23 to address this issue ( WE DID NOT ACTUALLY HOST THIS TRAINING I DON'T KNOW WHAT TO SAY BECAUSE SHE WENT TO THE HOSPITAL THE 12/1/23) 12/01/2023 Implemented
SIN-00262048 Unannounced Monitoring 03/06/2025 Compliant - Finalized
SIN-00248974 Unannounced Monitoring 06/06/2024 Compliant - Finalized
SIN-00236217 Unannounced Monitoring 12/04/2023 Compliant - Finalized