Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279919 Renewal 12/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1's annual assessment was not completed annually. Individual 1's initial assessment was completed on 3/15/24. The annual assessment was not completed until 5/2/25. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist did not follow the initial assessment date; she instead was waiting for the ISP review date which was off track. The PS did two different assessments one reflecting the annual from the initial assessment and did another one for the ISP review date. 02/20/2026 Implemented
6400.34(a)Individual #1's individual rights were not reviewed annually. Individual #1's individual rights were reviewed on 1/10/24 and not again until 1/16/25.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Program specialist indicated that the right was signed on time but dated later. Program specialist will keep the current date for review in the future and ensure all review are done and signed a day before or on the exact date. 02/20/2026 Implemented
6400.165(b)Prescription orders are not kept current. Individual #1 is prescribed Ketazoncole Shampoo. There are two labels on the bottle with conflicting instructions. The first label states to apply topically to wet hair, lather rinse use every 3-4 days up to 8 wks. dandruff. The second to wet hair as needed to control dandruff.A prescription order shall be kept current.After the 8 weeks used, the doctor changed the order to PRN, but supervisor did not remove the old label to replace new one and discontinued the first instruction. The supervisor went to the doctor, and the order was changed/Discontinued. 02/20/2026 Implemented
6400.181(f)Individual #1's annual assessment dated 5/2/25 was not sent to the team at least 30 days prior to Individual #1's Individual Support Plan meeting on 6/13/25.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist did not send the assessment to the team in time before the individual ISP meeting was held .The PS will keep the past ISP review dates on file as the date on going. 02/20/2026 Implemented
SIN-00241484 Renewal 03/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At time of inspection the paneled walls in the right section of the basement were mostly covered in a substance that appeared to be a light colored mold. Floors, walls, ceilings and other surfaces shall be free of hazards.It is hazardous to have mold and other toxic substances that are harmful in the home. Something like mold, although it was not confirmed to be mold was on the basement wall. There was a form of dust from the floor on the basement walls, it was not confirmed as mold by the landlord maintenance. The agency maintenance cleaned the wall with power wash and spray cleaned the entire wall. 03/29/2024 Implemented
6400.110(a)The back living area of the home contained a set of pull-down stairs that lead up to an attic area. There was no smoke detector located in the attic area. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. This regulation is important for staff and individuals¿ safety in the event of fire emergency. The attic did not have smoke detector at the time of inspection. We have informed that landlord to give us access to the attic and our maintenance has installed smoke detector. 03/30/2024 Implemented
6400.110(b)Smoke detector by bedroom Inhabited by Individual #1 was not operable at the time of inspection. There was not another detector located within 15 feet.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. This regulation is important in preventing serious injury or death in fire emergency. The smoke detector was there, but the battery was not properly installed. 03/30/2024 Implemented
6400.111(a)The back living area of the home contained a set of pull-down stairs that lead up to an attic area. There was no fire extinguisher located in the attic area.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. This regulation is important for staff and individuals¿ safety when there is a fire emergency. The attic did not have fire extinguisher at the time of inspection. We have informed that landlord to give us access to the attic and our maintenance has installed fire extinguisher 03/30/2024 Implemented
6400.32(r)At time of inspection the bedroom door for Individual #1 had a coin key lock. Coin key locks do not afford privacy as a coin key lock does not require a unique locking mechanism.An individual has the right to lock the individual's bedroom door.This regulation gives or ensures the individual¿s right to privacy in their bedroom. The individual has the right to have a lock on his bedroom door. At the time of the inspection, the individual door did not have a key lock his door. We have put a key lock on his door at this time, we will discuss this more with the county to decide and will be sure it is in his ISP. 03/16/2024 Implemented