Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292425 Renewal 06/02/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(4)At 12:10 PM on 6/3/2026, Individual #1's bedroom door was equipped with a privacy lock having a pinhole access point on the outside. However, this locking assembly does not allow easy and immediate access by the individual and staff persons in the event of an emergency. Individual #1 documented their declination for a bedroom lock on 12/20/2024.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Upon identification of the citation, the agency immediately assessed the bedroom door locking mechanism to ensure it met HCBS and ODP requirements. The existing privacy lock with a pinhole emergency release was determined not to provide easy and immediate access for both the individual and staff during an emergency. Although the individual had previously declined a bedroom door lock on 12/20/2025, the agency discussed the individual's current preferences on 6/3/2026 and the individual continued to decline a locking mechanism on their door. Their decision was documented. The non-compliant locking mechanism has been removed and replaced with a non-locking doorknob as per the individuals request. 06/05/2026 Implemented
SIN-00271444 Renewal 07/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 2/20/24 at 02:00 AM did not include the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drills will be tracked by the Operations Manager. Fire Drills will be submitted to the Operations Manager by the 15th of each month to ensure the fire drill was conducted and the date, time, the amount of time it took to evacuate, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative are tracked on the fire drill sheet and correct. The Assistant Executive Director will then review and file these fire drill documents. [A blank "Fire Drill and Safety Checklist" form, that includes evacuation time, was received on 8/27/25 and reviewed 9/4/2025. DPOC by HDKP, HSLS, on 9/4/2025.] 08/01/2025 Implemented
SIN-00230191 Renewal 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(4)Chief Executive Officer #1's annual training hours for the annual training year, 1/1/2022 through 12/31/2022, did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.CEO, completed assigned training modules encompassing Recognizing and Reporting Incidents via CDS on 09/22/2023. EIG Services LLC assessed training transcripts and training plans of Executive and Other administrative positions staff to ensure annual training hours encompass Recognizing and Reporting Incidents and other regulatory requirements. 09/22/2023 Implemented
SIN-00213132 Renewal 09/07/2022 Compliant - Finalized
SIN-00193401 Renewal 09/21/2021 Compliant - Finalized
SIN-00191432 Unannounced Monitoring 08/17/2021 Compliant - Finalized
SIN-00185141 Unannounced Monitoring 03/23/2021 Compliant - Finalized
SIN-00178842 Renewal 11/04/2020 Compliant - Finalized