Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241976 Renewal 05/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Each individual shall have an annual assessment with in 60 days of admission and annually thereafter. Individual #1 annual assessment dated 5/16/22 and 5/17/23 was the same exact assessment. Both assessments front page reflected 5/16/22, in addition every section had the same summary with the same words and scoring. The only difference was the date on the signature line. The assessment shall be updated annually. These assessments appeared to be the same exact copy from 5/16/22.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
2390.151(e)(3)(ii)The annual assessment dated 5/17/23 did not have progress and growth in the area acquisition communication, ability to receive, retain and carry out instructions.The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
2390.151(e)(3)(iii)The annual assessment dated 5/17/23 did not have progress and growth in the area acquisition of personal adjustment.The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal adjustment.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
2390.151(e)(13)(i)The annual assessment dated 5/17/23 did not have progress and growth in the area acquisition of healthThe assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
2390.151(e)(13(iv)The annual assessment dated 5/17/23 did not have progress and growth in the area acquisition of socialization.. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
2390.151(e)(13)(v)The annual assessment dated 5/17/23 did not have progress and growth in the area acquisition of vocational skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Program specialist for the program will receive re-training on how to complete assessments, and the requirements for assessments. 05/31/2024 Implemented
SIN-00207064 Renewal 05/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(a)The fire alarm was inoperable at the time of inspection.There shall be an operable fire alarm that is audible throughout the facility.Smoke detectors were purchased and placed in the program area and lunchroom. They will remain in use as a precaution, in the event that another issue with the upstairs tenants would cause the wired fire alarm to malfunction. The wired fire alarm was successfully put back into service on 7/15/22, after the damage from the issue was repaired. 07/15/2022 Implemented
2390.49(c)(3)Staff #1 and Staff#2 did not receive annual training in training year 2021 on Client rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.The annual training plan was updated to ensure that Individual Rights training is identified as a required training for all agency provider staff. Each staff was sent a copy of the updated training plan. 05/20/2022 Implemented
2390.49(c)(5)Staff #2 did not receive annual training in training year 2021 on the safe and appropriate use of behavior supports.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 a client.The annual training plan was updated to clearly identify Positive approaches- restrictive procedures as a required training for all agency provider staff. Each staff was sent a copy of the updated training plan. 07/19/2022 Implemented
SIN-00124147 Renewal 01/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(b)The annual fire safety inspection was conducted on 10/14/2016. The next fire safety inspection was conducted on 11/2/2017, which exceeds the annual requirement.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.In order to have the site inspected within 2390 guidelines, the site supervisor will contact the fire chief two months in advance to make sure they arrive by the due date of the annual inspection. Although the city may be late in inspecting, contacting them early will now allow for ample amount of time for them to do the inspection. 01/04/2018 Implemented
SIN-00104402 Renewal 02/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(b)Staff #1 was hired on 10/5/2015. In the 2016 training year, she had 20.5 hours. This is 3.5 hours short of the 24 hours of annual training requirement. Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually.Staff are required to send their monthly training spreadsheet via email to their immediate supervisor to track hours accordingly. This will help staff monitor their trainings and make sure they have enough hours as required for the year. 02/06/2017 Implemented
SIN-00066032 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 did not receive fire safety training on an annual basis. The last date of fire safety training was 7/1/2013.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Staff and consumers will receive Fire Safety Training on an Annual basis. The actual Fire Safety Training includes a DVD with current Fire Safety Techniques. The Supervisor who is preparing the Fire Safety Training will have each staff and consumer sign and date the form upon completion. The Fire Safety Training will be kept in the front of the Fire Drill Book. After each fire drill practice, the supervisor or Program Specialist will review the current documentation, guaranteeing that all trainings and monthly fire drills are correct and completely documented as required. 10/29/2014 Implemented
SIN-00222285 Renewal 05/18/2023 Compliant - Finalized
SIN-00165211 Renewal 11/19/2019 Compliant - Finalized
SIN-00144666 Renewal 11/30/2018 Compliant - Finalized
SIN-00085887 Renewal 12/30/2015 Compliant - Finalized
SIN-00053920 Renewal 09/12/2013 Compliant - Finalized