Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246649 Renewal 06/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65At 12:30PM on 6/18/2024, the mechanical ventilation fan was inoperable in the bathroom in the basement of the home.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The vent in Center Avenues bathroom was immediately repaired on 6/18/2024 by Maintenance Director #4. 06/18/2024 Implemented
6400.106The home's furnace was cleaned and inspected on 9/26/2022 and 9/27/2023 by an agency employee and not by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. CLC will schedule furnace cleaning and inspection with Goods Heating for each site to be completed by September 30, 2024. We will obtain an invoice for each site that specifies the date and that cleaning and inspection was the service provided. Persons Responsible: Maintenance Director #4 09/30/2024 Implemented
6400.112(a)An unannounced fire drill was not held during December 2023. An unannounced fire drill shall be held at least once a month. There was no way to correct this violation from December. All sites with the exception of Fulton, Vermont, Unity, Frank and Dell Way did not have a December fire drill ran. 07/01/2024 Implemented
6400.214(b)On 6/18/2024, the most recent copies of Individual #1's physical examination, dental examination, dental hygiene plan, assessment and Individual Service Plan were not present in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The items from SS's record that were missing from the individual home record (physical exam, dental exam, dental hygiene plan, assessment and ISP) were appropriately filed in the home record on July 3, 2004. Responsible Party: Program Specialist #3 and Center DSP Supervisor #6. 07/03/2024 Implemented
6400.52(c)(5)Program Specialist #1's trainings for the annual training year, from 1/1/2023 to 12/31/2023, did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Between June 20, 2024 and July 1, 2024 Program Specialists received training / reviewed all Behavior Support Plans for the individuals that they monitor. Responsible Party: Residential Director #5 and Program Specialists: #1, #2, #3. 07/01/2024 Implemented
6400.52(c)(6)Program Specialist #1's trainings for the annual training year, from 1/1/2023 to 12/31/2023, did not encompass the implementation of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Between June 20, 2024 and July 1, 2024 Program Specialists received training / reviewed all ISP¿s for the individuals that they monitor. Responsible Party: Residential Director #5 and Program Specialists: #1, #2, #3. 07/01/2024 Implemented
6400.166(a)(5)Individual #1's June 2024 Medication Administration Record did not include the strength of Tylenol.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.On June 18, 2024 the necessary contact was made to the Dr and Pharmacy to have the ¿strength¿ of SS¿s PRN Tylenol to her prescription label and MAR. Responsible Party: Program Specialist #3 and Center DSP Supervisor #6 06/18/2024 Implemented
SIN-00208820 Renewal 07/27/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 7/27/22 at 2:10PM, the bathroom behind the stairwell in the basement of the home did not have mechanical ventilation and the window was unable to be opened.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. CLC Maintenance team fixed the window in questions so that it was operable and could be opened. This occurred on the day of the inspection of PA Ave (July 27, 2022). [Picture provided to ODP via email]. 07/27/2022 Implemented
6400.66On 7/27/22 at 2:15PM, the light fixture containing a light bulb in the ceiling near the stairwell in the basement of the home stairwell did not illuminate. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. CLC Maintenance team fixed the light fixture in questions so that it was operable. This occurred on the day of the inspection of PA Ave (July 27, 2022). [Picture provided to ODP via email]. 07/27/2022 Implemented
SIN-00093790 Renewal 04/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Indivdual #1's record did not include color of hair, color of eyes, identifying marks and religious affiliationEach individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.(Michele Britt)MB¿s Emergency Medical Information (EMI) form was update to include the missing information of hair color, eye color, identifying marks and religious affiliation. (EMI for MB sent to licensing 5/13) EMI forms for all 57 individuals in the residential program have been reviewed. Three were found to have the identifying marks field incomplete (TZ, ML, CP); another 5 were missing religions affiliation (JS, ML, DM, JC, JS). (EMI for these folks sent 5/13). The functionality of the EMI form is being updated to include the print function to be enabled only once all required fields are complete / have something typed into them. (Verification will be sent by July 1, 2016) 05/12/2016 Implemented
SIN-00041244 Renewal 10/31/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101RNC - The closet in the bathroom has a padlock on the door obstructing egress. Fully Implemented - PE - 2-14-13Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Staff at the site and all DSS Supervisors have been retrained on 12/6/12 in reporting unsafe conditions via Work Orders immediately to the Maintenance Director on physical site. Included in the DSS Supervisor training was an emphasis on this particular violation, which consisted of a padlock on a closet door. All DSS Supervisors have been retrained again on non-compliance issues with regard to padlocks and have been aware that any area large enough for a person to be placed into or get into cannot be locked. The Residential Director is responsible for this training. A monthly checklist has been created for maintenance staff to inspect and insure all areas of compliance with regards to interior and exterior physical site and safety for all residents who reside within the sites. A daily checklist has been developed for DSS Supervisors and staff to complete and monitor all areas of compliance with regards to interior and exterior.Any non-compliances if found will immediately be placed on a Work Order and sent to the Maintenance Director so repair/modifications can be made. The Maintenance Director is responsible for making all corrections to bring site back into compliance as Work Orders are received or non-compliances are observed by maintenance staff expeditiously. 12/13/2012 Implemented
6400.141(a)The physical examination for Individual #1 was not completed annually. The current physical is dated January 27, 2012 and the previous physical examination was dated January 5, 2011. Fully Implemented - PE - 2-5-13(a) An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The DSS Supervisor has been retrained on 12/6/12 in insuring dates are secured for annual physical exams that allow the individual to remain in compliance with 6400 Regulations. DSS Supervisors have been instructed to secure appointments for annual exams at least one month before they are due and turn these dates into the appropriate Program Specialist, who will assist in tracking to insure compliance. Two physicals have been included in the hard-copy packet to demonstrate compliance since this violation. 12/13/2012 Implemented
6400.186(b)The three month Individual Support Plan reviews for Individual #1 for July through September 2012, April through June 2012, January through March 2012 and October through December 2011 were not dated by Individual #1 and Staff #1. Partially Implemented - Adequate Progress - PE - 2-14-13(b) The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. partially implemented PE 2-5-13Both Residential Program Specialists have been retrained on 12/6/12 on insuring that all ISP Reviews are done within 3 months of the prior ISP Review and, upon completion, are signed and dated by the appropriate Program Specialist and Individual. Tbe Program Specialists have also been made aware that, within 30 days of the completion of each Individual Review, it is the Program Specialists' responsibility to insure that the Reviews are disseminated to all team members unless a member has acknowledged that he or she does not want the review. This training was done by the Residential Director. A hard-copy of a blank ISP Review will be enclosed in the POC packet to demonstrate compliance. No ISP Reviews are due to be completed until January 2013 at which time we will forward a completed packet on to the appropriate licensing representative. Two Individuals Three month ISP Reviews were completed and submitted. 12/13/2012 Implemented
SIN-00267428 Renewal 05/28/2025 Compliant - Finalized
SIN-00154606 Renewal 04/30/2019 Compliant - Finalized