Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280065 Renewal 12/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)The smoke detector system in the facility would not sound during the months of July, August, September and October. A fire alarm was not set off during the drills completed within the specified time frame.An unannounced fire drill shall be held at least once a month.We have updated our fire safety policy for all sites, that if there is a delay in the company fixing the fire system that portable fire alarms will be put into place and checked during this time period. This ensuring that the system is always being checked. 12/26/2025 Implemented
2380.91(a)Individual #1 has a documented admission date of 4/16/25. There was no documentation that fire safety training had been completed upon initial admission. Documentation of fire safety completed on 10/1/25 was present.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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, and smoking safety procedures if individuals smoke at the facility.The Program Manager and Program Specialist will ensure that all new admissions have the requested Fire Safety completed. This will happen even when the Individual is within other programs due to being site specific. 12/26/2025 Implemented
2380.111(c)(4)The vision section was not completed on the physical dated 10/3/24 for Individual #1. The vision and hearing sections were not completed for the on the physical dated 9/26/25 for Individual #2.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Both Individual's parents have been contacted about getting documentation from their primary care physician about their hearing and vision screening. Their files will be updated when we receive the information. 12/26/2025 Implemented
2380.111(c)(5)There was no documentation that a Tuberculin skin test had been completed within one year prior to admission on 4/16/25 for Individual #1.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.The Program Specialist will ensure that before starting the program that the TB test is within the year before starting the program. 12/26/2025 Implemented
SIN-00257197 Renewal 12/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill conducted on 7/30/24 did not include the time the fire drill was conducted as this section was left blank on the form.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 was operative.Staff have been retrained on filling out all spaces of the fire drill correctly and completely. This was completed by the Director to the Manager of the ATF program 01/21/2025 Implemented
2380.89(d)The fire drill conducted on 3/4/24 at 9:30 am had an evacuation time of 3:29 (three minutes and 29 seconds), the fire drill conducted on 5/16/24 at 11:30 am had an evacuation time of 2:45 (two minutes and 45 seconds), which exceeds the 2 ½ minutes.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.All staff have been retrained in the regulation concerning fire drills over 2 minutes 30 seconds. Moving forward staff will also notify the Director of any drills that are over the time limit. 01/21/2025 Implemented
2380.111(c)(7)Individual #2's physical examination dated 10/21/24 did not include health maintenance needs as this section of her physical examination was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Director has retrained Managers and Program Specialist about looking over a physical when it is returned to ensure that all parts of the physical are completed. 01/21/2025 Implemented
2380.21(l)There was no record of documentation in Individual #1 and Individual #2's files that the agency had at least one conversation and documented it from July 1, 2024, through September 30, 2024, regarding conversations with Individual #1 and Individual #2 relating to their preferred community participation and activities at least quarterly.An individual has the right to make choices and accept risks.Program Specialist was retrained that this regulation also covers 2380 programs as well as the 2390's. 01/21/2025 Implemented
2380.21(u)Individual #2 did not have a review of their rights in 2024.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Individual was attending the ATF the day of inspection and this was reviewed and completed with them. The Program Specialist was retrained on watching the due dates for each Individuals especially when they started outside of the new year. 12/27/2024 Implemented
SIN-00236242 Initial review 12/12/2023 Compliant - Finalized