Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269890 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill completed on 2.6.25 at 2:10pm did not list the exit route used. That area of the report was left blankA 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. All Program staff members have completed a refresher training course on how to complete the fire drill form on July 24th, 2025. 08/04/2025 Implemented
6400.112(e)There was a sleep drill documented on 8.23.24 at 12:30am, however there was not another sleep drill documented for this home. The Feb 2, 2025 drill checked the "sleep box" however the time that was noted was 12:30pm which is not in fact sleep hours.A fire drill shall be held during sleeping hours at least every 6 months. All Program staff members have completed a refresher training course on how to complete the fire drill form on July 24th, 2025. 08/04/2025 Implemented
6400.151(a)Staff #2 had his initial physical on 2.25.22 and did not have another physical completed until 3.7.24. This exceeds the two-year time frame required under the regulation. 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. An annual physical tracking form has been created to ensure accurate and on time completion of all future staff member physicals. Staff will receive a first notice about their upcoming physical 45 days before the physical is due. A second notice will be sent 30 days before the due date. A final notice will be sent 15 days prior to the due date. 08/04/2025 Implemented
SIN-00250043 Renewal 08/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisonous materials shall be stored in their original, labeled container. An unlabeled decorative dispenser filled with a potentially poisonous liquid was found in the bathroom located in the staff office. The unknown substance in the dispenser was not stored in its original labeled container.Poisonous materials shall be stored in their original, labeled containers. The unlabeled decorative dispenser was trashed upon discovery during licensing inspection. 09/30/2024 Implemented
6400.171Food shall be protected from contamination while being stored, prepared, transferred and served. A large bag of white rice was found stored in a lower cabinet in the kitchen. The bag of rice was wide open, without a closure or in a closed container, leaving the contents unprotected from potential contamination.Food shall be protected from contamination while being stored, prepared, transported and served. The bag of rice was immediately removed from the kitchen lower cabinet during the time of inspection and stored in a lock container. 09/30/2024 Implemented
6400.163(b)Medications may not be removed from its original, labeled container in advance of the scheduled administration. At the time of the medication review on the afternoon of August 19, 2024, the 10 mg. tablet of melatonin to be administered at 8 PM on August 19, 2024, was found to be missing from the blister pack. The medication had been popped from the blister pack at an unknown time and the whereabouts of the missing tablet was also not known.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.A refresher training on Medication Administration has been completed for all the staff working in the home to ensure PA 15 medication administration steps are always followed during medication administration. 09/30/2024 Implemented
6400.166(a)(11)The August 2024 Medication Administration Record (MAR) for Individual #1 did not record a diagnosis or purpose for the medication azelastine 0.1% nasal spray.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1 Primary Care Physician was contacted, and a script was sent to the Pharmacy that contained the diagnosis of the medication. The Pharmacy has sent a new MAR with the medication diagnosis on the new MAR. 09/30/2024 Implemented