Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281060 Renewal 01/05/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The fire department notification letter dated 1/1/2026 did not give an accurate description of the mobility needs of individuals residing at this address. The letter states "the current occupants are ambulatory and able to safely evacuate in case of an emergency without further assistance needed". Individual #1 requires verbal prompts to safely evacuate, as indicated in Individual #1's assessment, dated 2/28/25.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Updated notification letters for Alternative Living Concepts were provided to the local fire department to ensure emergency responders have accurate, current information to support safe evacuation during an emergency. Revised fire department notification letters now include: The individual's ambulatory status and whether verbal prompting and/or physical guidance is required during evacuation. 01/12/2026 Implemented
6400.181(e)(14)Individual #1's annual assessment that was completed on 2/28/25 did not address the knowledge of water safety, to include the ability to temper water for handwashing and bathing.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Alternative Living Concepts has updated Individual #1's annual assessment to include the required information regarding knowledge of water safety, including the ability to temper water for handwashing and bathing, and the individual's progress over the last 365 calendar days. The revised assessment has been completed, signed, and placed in the individual's record. 01/12/2026 Implemented
6400.46(b)Direct Service Worker #1 completed fire safety training on 9/24/24 and then again on 10/15/25. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Alternative Living Concepts has reviewed the training records for Direct Service Worker #1. Direct Service Worker #1 has been retrained on the mandatory annual training requirements as outlined in their job description to ensure understanding of annual fire safety training expectations. In addition, Direct Service Worker #1 has agreed to receive automated reminder notifications from the ALIS electronic health record system when training is due, in conjunction with existing reminder notifications provided by the Administrative Coordinator. These measures ensure timely completion of required annual training and ongoing compliance. 01/12/2026 Implemented
6400.52(c)(4)Direct Service Worker #1 does not have a record of completing the recognizing and reporting incidents annual training topic during the 2025 calendar training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Alternative Living Concepts has ensured that Direct Service Worker #1 completed the required Recognizing and Reporting Incidents training 1-5-2026. Documentation of completion has been obtained and placed in the employee's training record.(see attached ) 01/12/2026 Implemented
SIN-00259955 Renewal 01/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At 10:11 AM on 1/30/25, the interior door leading from the dining room to the basement had a crack measuring two feet in length across the second panel from the top of the door. The crack penetrated entirely through the door's structure on both sides. Screens, windows and doors shall be in good repair. The interior door, leading from the dining room to the basement, with a crack penetrating through the door's structure and measuring two feet in length across the second panel from the top of the door, has been repaired and repainted as of 2-5-2025. (see picture attached) 02/05/2025 Implemented
6400.141(a)Individual #1's date of-admission is 7/1/19. Their most recent physical examination was completed on 2/7/24. However, Individual #1's content of records did not include a physical examination completed in 2023 to measure annual compliance. [Repeated Violation-2/6/24]An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Effective 2-18-2025 ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. Going forward ALC will use ALIS to ensure that individual's physicals are conducted annually from recent physical date. 02/18/2025 Implemented
6400.141(c)(4)Individual #1's date-of-birth is 11/18/99. Individual #1 had a vision examination completed on 4/17/23 but did not have one conducted in 2024. A vision screening was not performed on Individual #1's most recent physical examination completed on 2/7/24. Individual #1 had a hearing examination completed on 6/2/23, and then again on 12/26/24. A hearing screening was not performed on Individual #1's most recent physical examination completed on 2/7/24.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Effective 2-18-2025 ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. Medical records coordinator and administrative coordinator will perform a 2-step review process to ensure dates for all parts of the physical examination are compliant to regulations. 02/18/2025 Implemented
6400.141(c)(14)Individual #1's most recent physical examination, completed on 2/7/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency. this section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. Medical Records coordinator and Administrative coordinator will preform the 2-step review process. This will ensure that all medical information pertinent to diagnosis and treatment in case of an emergency is documented 02/18/2025 Implemented
6400.181(e)(12)Individual #1's date-of-admission is 7/1/19. Individual #1's current assessment, completed on 2/28/24, did not include recommendations for specific areas of training, programming, and services. The corresponding field on the assessment read, "No recommendations at this time."The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program specialist was trained by the CEO on how to accurately document recommendations for specific areas of training , programming, and services. 02/10/2024 Implemented
6400.15(b)The agency used the Self-Inspection and Declaration Tool, modified June 2018 to measure and record compliance at the home on December 27, 2024, which does not contain all the elements in the current Department's licensing inspection instrument released on February 20, 2020.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.ALC disposed of all copies of the Self-Inspection and Declaration Tool modified June-2018 and replaced them with the correct version modified Feb-2020 as located in the 6400 Regulatory Compliance Guide printed March 15, 2023. The compliance managers, who are responsible for completing the Self- Inspection and Declaration Tool, were trained 2-20-2025 that going forward, the self- inspection and declaration tool modified Fed-2020 in the correct form to be used when conducting home inspections. 02/10/2025 Implemented
6400.32(r)(1)At 10:21 AM on 1/30/25, Individual #1's bedroom door was equipped with a privacy lock with a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #1 with a mechanism in which to lock and unlock their bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Bedroom door lock with a turn latch (interior) and a thumbnail, straightening access point (exterior), has been removed. A keypad door lock has been installed as of 2-4-2025. (see picture attached) 02/04/2025 Implemented
6400.32(r)(4)At 10:21 AM on 1/30/25, Individual #1's bedroom door was equipped with a privacy lock with a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Bedroom door lock with a turn latch (interior) and a thumbnail, straightening access point (exterior), has been removed. A keypad door lock has been installed as of 2-4-2025. (see picture attached) 02/04/2025 Implemented
6400.182(c)Individual #1's Individual Support Plan, last updated on 6/28/24, was not revised to reflect their current needs as based on their current assessment, completed on 2/28/24, in the following health and safety skill domains: regarding water safety, Individual #1's Individual Support Plan stated that they have an understanding of general water safety and that they can regulate their own water temperature but did not address their ability to swim or the level of supervision required when doing so. Individual #1's assessment indicated that they have an understanding of general water safety, that they can regulate their own water temperature, and that they can swim; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan left this skill domain unaddressed entirely, while their assessment indicated Individual #1 can independently sense and quickly move away from such heat sources; and regarding supervision, Individual #1's Individual Support Plan stated that they require 19 hours of supervision in the home and that they can have five hours of "downtime" in both the home and community with no specificity in terms of how their "downtime" is allocated between the two environments. Individual #1's assessment informed that they require a 1:2 staff-to-individual ratio in the home and indicated vaguely that they can be left unsupervised in the community.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.CEO trained the program specialist on how to properly assess and document the following areas: 1. General Water Safety 2. Non-Insulated heat sources 3. Supervision Supervision for the individual should address: Supervision in the bedroom, supervision in the home and supervision in the community. 1. General Water Safety: Individual #1 has the ability to regulate water temperature. he has demonstrated in front of staff that he is capable of regulating his own water temperature for the shower/bath. According to the individual he is capable of swimming independently with out supervision. He has successfully demonstrated his ability to swim in up to six feet of water when at the pool with Auberle Day Program staff. 2. Non-insulated Heat Sources: Individual #1 has the ability to sense and move away from heat sources. 3. Supervision Supervision in the bedroom: Individual #1 is high functioning and verbally communicates his wants and needs very effectively. He does not require supervision in the bedroom. Supervision in the home: Individual #1 does not require eyes on or face to face monitoring because he will seek assistance from the staff if needed. Individual #1 has five hours of downtime in which he can spend in the home if he chooses to do so. Individual #1 has five hours of downtime in the home, five hours of downtime in the community, or a combination of the two. Supervision in the community: Individual #1 has five hours of downtime he can use to go into the community without staff supervision. individual #1 is capable of taking a bus to and from his family members home, to and from social activities, or to and from visiting his friends. 02/17/2025 Implemented
SIN-00238727 Renewal 02/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The smoke detectors in the home were not interconnected when tested at 1:32PM. [Repeat violation 2/13/2023 et al]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. On 2/9/2024, the owner of Meridan Contacting removed one KIDD 10-year smoke detector from the living room of Home. This smoke detector is not a part of the X-Sense smoke detector system which is interconnected on all 4 floors of the unit. Once the KIDD 10-year smoke detector was removed, the X-Sense smoke detectors were operational on all 4 floors. (owner) instructed the supervisors on the correct way to test the X-Sense smoke alarm 10-year interconnecting system. 02/09/2024 Implemented
6400.111(f)A fire extinguisher in the attic has not been inspected and approved by a fire safety expert since November 2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On 2/9/2024, the fire extinguisher located in the attic of the home was inspected by Summit Fire & Security. (A Photo of the tagged fire extinguishers will be submitted with the POC.) 02/09/2024 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was 6/19/23.A fire drill shall be held during sleeping hours at least every 6 months. As of 2/14/2024. ALC's fire drill report form was updated to ensure compliance with regulation 6400.112(e). The CEO informed and provided supervisors with the updated documentation. 02/14/2024 Implemented
SIN-00219196 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:18AM on 2/14/2023, the bathtub in the second floor bathroom had a thick layer of dirt and hair.Clean and sanitary conditions shall be maintained in the home. The provider has updated the agency chore list and staff duties to require staff to immediately clean the bathtub after each time an individual uses it.- 3/1/23 03/15/2023 Implemented
6400.67(b)The stairs leading to the attic of the home have several nails protruding from each step. Floors, walls, ceilings and other surfaces shall be free of hazards.All nails have been removed from the attic steps- 2/19/23 03/15/2023 Implemented
6400.72(a)There are not screens in the two windows in the attic of the home.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens have been purchased and installed in the cited windows. Proof of purchase and installation documentation have been obtained.- 2/23/23 03/15/2023 Implemented
6400.74The stairs leading to the attic of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. the attic steps cited have been painted with a non skid surface paint. The name of the paint is HC Shark Grip Slip Resistant Additive. Photographs of the steps and proof of purchase have been retained for documentation. 2/20/23 03/15/2023 Implemented
6400.82(f)There were not individual clean paper or cloth towels in the bathroom in the basement of the home.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. The provider has updated the agency chore list and staff duties to require staff to ensure all toiletries are present in all bathrooms, including paper towels.- 3/1/23 03/15/2023 Implemented
6400.105At 10:12AM on 2/14/2023, the lint trap in the clothes dryer had a half inch thick layer of lint.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The provider has updated the agency's daily chore list and staff duties to require staff to ensure the lint trap of the dryer is emptied before and after each use, in addition to being check during daily chores..- 3/1/23 03/15/2023 Implemented
6400.110(e)At 10:26AM on 2/14/2023, the smoke detectors on each of the four floors of the home were not interconnected.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. Interconnected smoke detectors were purchased and installed. Documentation of purchase and installation have been retained. 2/28/23 03/15/2023 Implemented
6400.214(b)Individual #1's most recent Individual assessment was not present at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Interconnected smoke detectors were purchased and installed. Documentation of purchase and installation have been retained. 2/28/23 03/15/2023 Implemented
6400.163(h)There were two packets, of "Non-Aspirin" medication that expired in 12/2022, in the first aid kit.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The expired medication has been removed from the home and discarded. 2/15/23 03/15/2023 Implemented
SIN-00202483 Renewal 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)The agency is the representative payee for Individual #1. The home did not keep an up to date financial and property record for Individual #1 to include: disbursements made to or for the individual.(2) Disbursements made to or for the individual. The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 04/22/2022 Implemented
6400.22(e)(1)The agency is the representative payee for Individual #1.The home did not keep a separate record of financial resources, including the dates and amounts of deposits and withdrawals for Individual #1. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 04/22/2022 Implemented
6400.22(e)(2)The agency is the representative payee for Individual #1. The home did not keep a record of withdrawals for when Individual #1 is given the money directly , the record shall indicate the funds were given directly to the individual. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 04/22/2022 Implemented
6400.22(e)(3)The agency is the representative payee for Individual #1. The home did not keep documentation, by actual receipt or expense record of each single purchase exceeding $15 made on behalf of Individual #1 carried out by or in conjunction with a staff person. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 04/22/2022 Implemented
6400.68(b)On 3/2/22, at 11:02 AM, the water temperature was measured 143.4 Fahrenheit at the second-floor bathtub. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 3/2/22- The water temperature was adjusted to 118.7 degrees. The agency has added a "water temp check" section on the fire drill log. This will ensure the water temperature is checked and recorded on a monthly basis. If it is found the temperature is beyond the 120 degrees regulatory requirement, staff will immediately adjust it to 118. degrees. [Copy of monthly fire drill form that includes a measurement of water temperature received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 04/01/2021 Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed on 11/25/20 and then again on 5/19/21, exceeding the 90-day requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The agency CEO has sent several request (verbal phone conversation) to the psychiatric doctor to receive proof of med reviews for 2021 - in which the response was "they will eventually send them when they find them". On another occasion, the medical office stated the records were at another office and they would get back to us. As of April 20, 2022, the psychiatric office has not located or answered ALC's request. The agency has developed an "information request form". The form includes the following: 1. Date of request 2. Staff making request 3. information requested 4. reason for request 5. who staff made contact with 6. Results of the request ***PLEASE NOTE: the individual from the dunbar site, and this site (both have the same psychiatric providers.*** ["Information Request Form" received on 5/19/22 and reviewed on 5/20/22. "Individual Data Tracking" system received 5/19/22 and reviewed 5/20/22. Weekly reviews by Administrative Liaison received 5/19/22 and reviewed 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 03/29/2021 Implemented