Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281922 Renewal 01/28/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)Interior stairways and outside steps exceeding 2 steps shall have a well secured handrail. At the time of the inspection the basement area had an exit that lead to Bilco doors. There was no hand railing. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A properly secured handrail has been installed on the basement stairway leading to the Bilco doors. The handrail met all safety and regulatory requirements, including appropriate height, secure mounting, and durability. 02/06/2026 Implemented
6400.80(a)Outside walkways shall be free from ice and snow. At the time of the inspection the side door exit did not have a clear pathway. The area was full of snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. Immediately following the inspection, staff cleared the side door exit and the surrounding walkway to ensure it was completely free of snow and ice. Ice melt was applied to prevent refreezing and ensure safe passage. 01/29/2026 Implemented
6400.82(f)The bathroom located in the basement of the home did not have paper towels or a cloth towel at the time of inspection.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. At the time of inspection, the bathroom located in the basement did not have paper towels or a cloth towel available. Immediately upon discovery, program staff stocked the bathroom with paper towels. All bathrooms in the home were rechecked the same day to ensure compliance. 01/28/2026 Implemented
6400.111(f)The fire extinguisher shall be inspected and approved annually by a fire safety expert. The fire extinguisher located in the kitchen cabinet under the sink did not have the year of inspection documented. The month was April; however the year was not marked. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. During inspection, the fire extinguisher located in the kitchen cabinet under the sink was found to have the inspection month (April) documented, but the inspection year was not recorded. Immediately upon discovery during the inspection, the fire safety company was contacted to verify the inspection date. The extinguisher was re-tagged with the correct month and year of current inspection. 01/29/2026 Implemented
6400.151(a)Staff that have direct contact with individuals shall have a physical exam 12 months prior to employment and every 2 years thereafter. Staff #1 had a physical exam on 2.24.22 and not again until 8.6.25. This exceeds the time frame. 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. During the CEO's audit of staff files, it was identified that Staff #1 had not completed the required physical examination. HR was notified and promptly instructed Staff #1 to complete the physical at the agency's designated clinic. Staff #1 has since completed the required physical exam as of 8/6/25, and the documentation has been added to the employee's personnel file. 01/28/2026 Implemented
6400.163(d)Prescription medications shall be kept in a locked area. Individual is prescribed Abuterol as needed every 6 hours for wheezing. At the time of inspection, the abuterol was not located in the medication box with the rest of the medications. Staff then located the inhaler on individual's bed. The medication shall be kept locked.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Upon discovery, staff immediately placed the Albuterol inhaler back into the locked medication storage area. All medications were verified to be present, properly labeled, and securely stored. 01/29/2026 Implemented
6400.213(1)(i)Violation is for 213(1)(iv). There is no corresponding drop box. The individual record shall contain their religious affiliation. That area of the document reflects "unknown".Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The Program Specialist spoke with the individual, who stated that he identifies as Christian. The Program Specialist then updated the individual's record to accurately document this information immediately. 01/29/2026 Implemented