Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260375 Unannounced Monitoring 02/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom window has a storm window behind the window screen that prevents ventilation when the bathroom window is 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. Violation 65 is noted. However, please be informed that the window has a double pane glass which navigates ventilation for the bathroom. Provider believes this was not properly reviewed during the inspection. However, the window pane has been adjusted accordingly. Please see POC attachment # 5 as documentation evidence for violation. 02/07/2025 Implemented
6400.66The light in basement needs to be changed.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Violation 66 has been corrected. See POC attachment #6. Accordingly, Provider will ensure light switches are operational to assure safety. 02/07/2025 Implemented
6400.67(b)Surfaces. The basement sump pump well had no cover. There was fraying of linoleum in the basement posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Violation 67 (b) has been corrected. See POC attachment # 7. Accordingly, Provider will ensure floors, walls, ceilings and other surfaces shall be free of hazards to assure safety. 02/07/2025 Implemented
6400.77(a)The first aid kit was not onsite. A home shall have a first aid kit. Violation 77 (a) was corrected and the first aid kit has been placed in its rightful location accordingly. It appeared that staff removed the kit from the cupboard in the kitchen to another location, making it inaccessible on that day of inspection. However, Staff were retrained on first aid kit protocols as far as location, organization and maintenance to maintain compliance. See POC attachments #8 and #9 02/08/2025 Implemented
SIN-00224011 Renewal 04/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The blinds in the bathroom are damaged and need replaced or repaired. Screens, windows and doors shall be in good repair. Violation 72 (b) was corrected. See attachment # 13. 04/29/2023 Implemented
6400.141(c)(6)TB for individual one says negative results, but the document does not list date of administration or reading.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Violation 141 (c) was identified on individual one file the day of inspection . See attachment #14. 04/29/2023 Implemented
6400.141(c)(10)On individual one's physical, physician indication that she is free from communicable disease is not listed on form.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Violation 141 (c) (10) was completed and documented accordingly. See attachment #15. 04/29/2023 Implemented
6400.213(8)(i)Binder for individual one did not contain ISP nor sign-in sheet for this year. Most recent ISP and Sign-In was dated for 3/1/22. Each individual's record must include the following information: A copy of the signature sheets for the initial ISP meeting. Violation 213 (8) (i) was completed and documented accordingly. See attachments # 16 & 17. 04/29/2023 Implemented
6400.163(h)Prescription medication NARCAN SPRAY was located in the individual one's med box. It expired on 01/13/2023.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Violation 163 (h) was removed from site and awaiting proper documentation from Physician. 04/29/2023 Implemented
6400.165(b)Medication NALOXONE 4mg nasal spray is in the individual one's med box and not listed on the MAR.A prescription order shall be kept current.Violation 165 (b) status is pending DC order from Physician. 04/29/2023 Implemented
SIN-00186420 Renewal 04/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)No exit route was listed on the fire drill form for the documented March 2021 drill.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. Program Supervisors have reviewed the March 2021 drill and other fire drill records at all licensed sites for completion and missing documentation. DSPs to be retrained on the proper documentation of fire drill records within one week of 05/20/21. Supporting documents to be emailed. 05/20/2021 Implemented