Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227829 Renewal 07/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)There was no smoke detector located in the attic of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detector was installed on 7/17/23. All other detectors in the home were verified to be working at the time. All staff in the home were retrained on 6400.110(a). 08/14/2023 Implemented
6400.111(f)The fire extinguishers were not inspected annually by a fire safety expert. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire extinguishers was inspected and tags were changed on 7/21/23. 07/21/2023 Implemented
6400.141(c)(14)On annual physical dated 3/13/23 for Individual #1 section 'information pertinent to diagnosis in case of emergency' was not filled out.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Physical form in question has been corrected as of 7/20/23. The form correctly identifies what needs to be documented by regulation, but simply was not filled out in this case. 07/20/2023 Implemented
6400.181(a)The two most recent annual assessments written for individual #1 were completed greater than 1 year apart. Assessments dated 5/17/22 and 6/7/23 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. The program specialist has developed a tracking system to identify the timeline for all individual's annual assessment. 08/15/2023 Implemented
6400.181(f)There was no documentation as to when the annual assessment was sent to the team for Individual #1.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist has developed a tracking system to identify the timeline for all individual's annual assessment to be provided to the individuals plan team member at least 30 days prior to an individual's plan meeting. 08/15/2023 Implemented
SIN-00200407 Renewal 07/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no light in the attic crawl spaceRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Light replaced in July 2021. 07/16/2021 Implemented
6400.76(a)The legs on both rocking chairs on the front porch were broken (the legs were separated from the bottom rocker) Furniture and equipment shall be nonhazardous, clean and sturdy. Rocking chairs removed immediately on 7/16/21 07/16/2021 Implemented
6400.111(a)There was no fire extinguisher in the attic crawl spaceThere shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. An extinguisher was placed in the attic on 7/21/21 07/21/2021 Implemented
6400.46(a)The staff struggled to disengage the fire alarm when it was triggered at the time of inspectionProgram specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.This Director has no record of training that was completed immediately after the inspection. 03/10/2022 Implemented