| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(a)(6) | On 7/12/2026 Sunset Support Services LLC management was notified of an alleged incident regarding Individual #1 communicating with a minor in a sexual nature and sending them a nude photograph. The nude photograph and conversation between Individual #1 and the minor have been shared on social media by an unknown source. Due to the exploitation of Individual #1 by an unknown source, it cannot be confirmed if a Sunset Support Services LLC employee is involved or not. The incident was not reported through the Department's information management system until 7/15/2026. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Exploitation
. | (Incident Management Representative), (Incident Management Specialist), and supervisory staff will be retrained on ODP Incident Management Bulletin requirements, with emphasis on timely reporting of suspected exploitation regardless of whether the alleged Perpetrator has been identified or agency involvement has been confirmed.
Robert Imler, CEO, will review and reinforce internal reporting procedures with all supervisory staff to ensure reportable incidents are entered into EIM within required timelines. |
08/11/2026
| Implemented |
| 6400.18(a)(8) | On 7/12/2026 Sunset Support Services LLC management was notified of an alleged incident regarding Individual #1 communicating with a minor in a sexual nature and sending them a nude photograph. The nude photograph and conversation between Individual #1 and the minor have been shared on social media by an unknown source. Individual #1 sharing a nude photograph of themselves with a minor prompts law enforcement involvement as the Individual may become subject to law enforcement activity leading to criminal charges. The incident was not reported through the Department's information management system until 7/15/2026. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| (Incident Management Representative), (Incident Management Specialist), and supervisory staff will be retrained on the Incident Management Bulletin requirements, with emphasis on timely reporting of suspected exploitation regardless of whether the alleged Perpetrator has been identified or agency involvement has been confirmed.
Robert Imler, CEO, will review and reinforce internal reporting procedures with all supervisory staff to ensure reportable incidents are entered into EIM within required timelines. |
08/11/2026
| Implemented |
| 6400.18(f) | On 7/12/2026 Sunset Support Services LLC management was notified of an alleged incident regarding Individual #1 communicating with a minor in a sexual nature and sending them a nude photograph. The nude photograph and conversation between Individual #1 and the minor have been shared on social media by an unknown source. Sunset Support Services LLC did not attempt contact with law enforcement until 7/14/2026 at 3:30pm to report a crime has been committed. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | , CEO, will review the incident reporting requirement withIncident Management Representative(Incident Management Specialist), and supervisory staff |
08/11/2026
| Implemented |
| 6400.18(h)(5) | On 7/12/2026 Sunset Support Services LLC management was notified of an alleged incident regarding Individual #1 communicating with a minor in a sexual nature and sending them a nude photograph. The nude photograph and conversation between Individual #1 and the minor have been shared on social media by an unknown source. Due to the exploitation of Individual #1 by an unknown source, it cannot be confirmed if a Sunset Support Services LLC employee is involved or not. As of 7/15/2026 a Department-certified investigator has not initiated an investigation. | A Department-certified incident investigator shall conduct the investigation of the following incidents: Exploitation. | , CEO, will review the incident reporting requirement with Li (Incident Management Representative), (Incident Management Specialist), and supervisory staff to reinforce the requirement that allegations of exploitation requiring investigation are promptly assigned to a Department-Certified Investigator and on the criteria for initiating investigations and required timelines. |
08/11/2026
| Implemented |
| 6400.186 | Individual #1's current Individual Service Plan dated 5/13/2026 and Behavior Support plan state that staff are required to complete a search of Individual #1's phone once a week at random and any additional searches will need to be approved by the office. Additionally, during behavioral sessions, a search may be completed. There is no documentation available that Sunset Support Services LLC staff have completed required phone searches. | The home shall implement the individual plan, including revisions. | (Behavior Specialist) will Immediately review Individual 1's BSP requirements with all staff responsible for implementing and documenting weekly phone searches.
will retrain staff on the importance of completing and documenting all required BSP intervention at the time they occur. will review documentation on a weekly basis to ensure required phone searches are completed and documented. will document this in individual 1's quarterly progress note. |
08/11/2026
| Implemented |