Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282470 Renewal 01/27/2026 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1, date of admission 10/03/2025, has no record of a tetanus and diphtheria vaccination completed.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. 01/28/2026 Individual #1 Tetanus/Diphtheria vaccination dated 07/10/2016 was given to Licensor. 07/10/2016 Not Implemented
6400.181(e)(1)Individual #1's assessment, completed by Program Specialist #1 on 7/31/2025, did not include the functional strengths, needs and preferences of the individual. This section was omitted entirely from the individual's assessment. The assessment must include the following information: Functional strengths, needs and preferences of the individual. 02/23/2026, Assessment for Individual updated to include functional strengths, needs and preferences. Updated Assessment emailed to Supports Coordinator. 02/23/2026 Implemented
6400.181(e)(11)Individual #1's assessment, completed by Program Specialist #1 on 7/31/2025, did not include a copy of the individual's psychological evaluation. Individual #1's support plan, last updated 11/12/2025 indicated that a psychological evaluation was completed by APS; however, the agency could not provide documentation that Program Specialist #1 attempted to obtain a copy of this evaluation.The assessment must include the following information: Psychological evaluations, if applicable. 01/30/2026, Psychological Evaluations secured and Assessments updated to reflect identified needs; emailed to Licensing Lead 01/30/2026. Updated Assessment emailed to Supports Coordinator 02/23/2026. 01/30/2026 Not Implemented
6400.181(e)(12)Individual #1's assessment, completed by Program Specialist #1 on 7/31/2025, did not include recommendations for specific areas of training, programming and services. This section of Individual #1's assessment stated, "[Individual #1]'s assessment and ISP."The assessment must include the following information: Recommendations for specific areas of training, programming and services. 02/23/2026 Assessment for Individual updated to include specific areas of training, programming and services. Updated Assessment emailed to Supports Coordinator. 02/23/2026 Implemented
6400.51(b)(3)Direct Service Worker #2, date of hire 7/10/2024, did not complete the initial Individual Rights training until 10/22/2024. This exceeds within 30 days after hire.The orientation must encompass the following areas: Individual rights.02/10/2026 Temporary Staff #2 documented completion of all required trainings. Trainings will be uploaded to Temporary Staff's file on Lifesteps network. 02/03/2026 Temporary Agency was notified via email by Administrative Assistant, Program Administration that Temporary Staff not in compliance with required annual trainings by 02/17/2026 will be suspended from working until compliance is documented. 02/10/2026 Not Implemented
6400.166(b)Individual #1's following prescription medications were not documented as administered on the January 2026 Medication Administration Record on 1/28/2026 at 8:00 AM: Ethosuximide 250 MG Capsule with directions to take 3 capsules by mouth twice daily, Lacosamide 200 MG Tablet with directions to table 1 tablet by mouth twice daily, Lamotrigine 200 MG Tablet with directions to take 1 tablet by mouth twice daily, Milk of Magnesia 400 MG/5 ML with directions to take by mouth twice daily, and Senna 8.6 MG Tablet with directions to take 2 tablets by mouth twice daily. [Repeat Violation, 1/29/2025, et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.02/11/2025 Community Home Supervisor conducted Medication Administration Record (MAR) Audit Individual #1's records for the Month of January 2026 to ensure medications were administered for each blank. 02/11/2026 Implemented
6400.182(c)Individual #1's assessment, completed by Program Specialist #1 on 7/31/2025, indicated that Individual #1 could swim independently; however, their support plan, last updated 11/12/2025, stated, "in large bodies of water [Individual #1] would need assistance/supervision with swimming." Individual #1's support plan has not been revised based upon the current assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.02/23/2026 Program Specialist #1 emailed Individual's updated Assessment to Supports Coordinator to request ISP update. 02/23/2026 Implemented
6400.213(1)(i)On 1/29/2026 at 11:35am, Individual #1's record did not contain personal information to include identifying marks. This section of the individual demographic page was left blank.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.02/23/2026 Individual #1's record was updated by Program Specialist. 02/23/2026 Implemented
SIN-00259582 Renewal 01/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional furnace cleaning company on 9/26/23, and then again on 11/1/24. This exceeds the annual requirement.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. By 02/28/2025, Buildings and Grounds Facility Manager will create and implement a common due date tracking Outlook Calendar that is accessible to Buildings and Grounds staff to ensure furnace inspections and cleanings are scheduled for completion 330 days from the last inspection date. 02/28/2025 Implemented
SIN-00201176 Renewal 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The window on the right in Individual #1's bedroom did not have screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. Lifesteps Buildings and Grounds staff installed the window screen on March 11, 2022. 03/31/2022 Implemented
6400.141(a)Individual #1's most recent physical examination was completed on 2-15-21.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Guardian scheduled individual #1 for physical on March 28, 2022. [As per Chief program officer on 4/6/2022, Individual #1's guardian confirmed Individual completed the scheduled physical examination on 3/28/22. Individual #1 is not currently living in the home and will not return according to Individual #1's guardian. ((AES,HSLS(4/6/2022)] 03/31/2022 Implemented
6400.141(c)(9)Individual #1's most recent prostate test (PSA) was completed on 1-4-21.The physical examination shall include: A prostate examination for men 40 years of age or older. Guardian scheduled individual #1 for prostrate examination (PSA) on March 28, 2022. [As per Chief program officer on 4/6/2022, Individual #1's guardian confirmed Individual completed the scheduled physical examination on 3/28/22 but did not have the prostate examination, this testing is to be rescheduled by Individual #1's guardian. Individual #1 is not currently living in the home and will not return according to Individual #1's guardian. (AES,HSLS(4/6/2022)] 03/31/2022 Implemented
6400.181(a)Individual #1, date of admission 5-10-21, had an initial assessment completed on 7-27-21. 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. Lifesteps Program Specialists will be retrained on Regulations 6400.181-190, including information in the Regulatory Compliance Guide by April 1, 2022. 04/01/2022 Implemented
6400.165(g)Individual #1's psychiatric medication reviews, completed 10-27-21 and 8-4-21, did not include the necessary dosage.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.Documentation for Individual #1's psychiatric medication reviews, including necessary dosage was received from doctor's office on March 4, 2022. 03/31/2022 Implemented
6400.166(a)(8)Individual #1 was prescribed Triple Paste Ointment on 5/20/21. The February 2022 and March 2022 Medication Administration Records states, "Apply topically as directed every morning for prevention of infection." The medication label states, "Apply topically to the rectum once daily (prevention of infection)."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.New labels were received from the pharmacy for the medication to replace incorrect label on March 4, 2022. 03/31/2022 Implemented
6400.166(a)(11)Individual #1's March 2022 Medication Administration Record does not include the diagnosis or purpose for Clobetasol cream.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.Updated Medication Administration Record was received by Community Home Supervisor from the pharmacy on March 4, 2022. 03/31/2022 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 7-27-21 to the plan team members on 7-27-21 for the annual ISP meeting on 7-30-21The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Lifesteps Program Specialists will be retrained on Regulations 6400.181-190, including information in the Regulatory Compliance Guide by April 1, 2022. 04/01/2022 Implemented
SIN-00091367 Renewal 03/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The outside lights on the front porch and near the sliding doors on the lower level of the home were not operable. There are not other sources of light in these areas. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Light bulbs were replaced on March 10, 2016. Community Homes Monthly Physical Site Checklist will be updated to include a check for working light bulbs in light fixtures.Community Homes Supervisors will be trained on revised Physical Site Checklist by April 30, 2016. [At least quarterly, Directors of the community homes will review the monthly checklist to ensure accurate completion and rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Documentation of checklist reviews shall be kept. (AS 4/25/16)] 04/08/2016 Implemented
SIN-00041533 Renewal 09/13/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's bedroom entrance area had a 2.5 foot stain, a 2 foot stain beside individual's bed, and various small circular stains throughout the carpet. Individual #2's bedroom had a variety of large and small stains throughout carpet. Fully Implemented. KD 3-20-2013.(a) Floors, walls, ceilings and other surfaces shall be in good repair. On 09/24/2012, the flooring the three bedrooms was replaced with a laminate. Photographs available upon request. A physical site checklist will be completed on a monthly basis. The program specialist or program director will be responsible for monitoring the checklist to ensure completion and to ensure that regulations are met. 12/28/2012 Implemented
SIN-00150391 Renewal 02/12/2019 Compliant - Finalized