Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00276977

Renewal

10/28/2025

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.65	On 10/29/25 at 11:14AM the downstairs bathroom did not contain a window or mechanical ventilation.	Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.	65- During licensing inspection on 10/29/2025, it was found that there was an additional toilet and sink added to the basement near the laundry area. When inspected, it was found that the bathroom did not have any form of ventilation. There were no windows in the bathroom nor was there a mechanical ventilation system in place. On 10/29/2025, TTSR Maintenance employee went to the site and installed a mechanical ventilation unit on the ceiling of the room near the bathroom door. Attached is a photo of the ventilation system (Image #1) That shows the ventilation system in place. TTSR Maintenance checked to ensure that the ventilation unit was operable before departing the site. A review of regulation 65 took place 10/30/2025. This review included the Site Supervisor as well as the TTSR Maintenance employee. Both acknowledge the need for ventilation in living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms to ensure air flow by window to outside or by mechanical ventilation. Compliance will be maintained by routine site inspections and monthly walkthroughs by both Site Supervisor as well as TTSR Administration and Maintenance department to ensure that this ventilation unit continues to remain operable and if repairs are needed, TTSR Maintenance will respond promptly to repair the unit if inoperable.	10/29/2025	Implemented
6400.81(h)	On 10/29/25 at 11:21AM, Individual #2's bedroom window contained a stained glass patterned film covering the window obstructing the view to the outside.	Each bedroom shall have at least one exterior window that permits a view of the outside.	81(h)- During licensing inspection on 10/29/2025, it was found that individual #2 had window tint over one window. This tint did allow for Individual #2 to have full sight of the outside area. On 10/29/2025, TTSR Maintenance employee went to the site and ripped off the window tint from the one window in the bedroom entirely. Attached are photos (from 10/29/2025) of the window and Image #1 shows that shows the exterior of the bedroom window after the tint was removed. Image #2 shows the interior of the window after the tint was removed from the window and you can clearly see the front yard. Image #3 is a view from the interior of the bedroom before the tint was removed and you clearly can not see the front yard of the home. A review of regulation 81(h) took place on 10/30/2025 with Site Supervisor as well as TTSR Maintenance worker. Both reviewed the regulation and acknowledge that they will ensure that no window has tint that prevents a view of the outdoors in the future. Compliance will be ensured by routine site inspections and monthly walkthroughs by both Site Supervisor as well as TTSR Administration and Maintenance department.	10/29/2025	Implemented
6400.32(n)	On 10/29/25 at 11:18AM the only telephone in the home was located in the locked staff office.	An individual has the right to unrestricted and private access to telecommunications.	32 (n)- During licensing inspection on 10/29/2025, it was found that the shared cordless phone for the site was located near the front door. However, the base/ charging port for the cordless phone was located in the staff office. With the port being in the staff room, this indicates that the Individuals of the site did not have direct access to the phone when the phone is/ was charging. On 10/29/2025, Site Supervisor for the site removed the charging port from the staff room and placed it in the kitchen area next to the stove (Image #1 attached). A review of regulation 32(n) took place on 10/30/2025 with Site Supervisor. Site Supervisor acknowledges that at all times, all Individuals residing at the site must have unrestricted and private access to telecommunications. Site supervisor acknowledges that the phone charger/ port will remain in the kitchen area and will not be relocated for any reason. Compliance will be maintained by routine site inspections and monthly walkthroughs by both Site Supervisor as well as TTSR Administration to ensure that all Individuals at the site have full unrestricted access to any telecommunication device at all times and that the phone charger/ port remains in a common area of thee home where Individuals can access at any time.	10/29/2025	Implemented
6400.46(b)	Direct Service Worker #1 completed fire safety training on 1/5/24 and again on 1/10/25. This exceeds the annual requirement.	Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).	46(b)- During licensing inspection, it was found that one DSP (Direct Support Professional) and one Administrator did not receive the Annual Fire Safety training within one year of the previous Fire Safety training. The DSP had Fire Safety training on 1/5/2024 and then the next on 1/10/2025 (5 days after the one year allotted timeframe with no grace period). The Program Specialist for TTSR had Fire Safety training on 1/5/2024 and then the next year on 1/9/2025 4 days after the one year allotted timeframe with no grace period). In past years, TTSR has scheduled Fire Safety in the month on January. As a Corrective Action, a review of regulation 6400.46(b) took place on 11/12/2025 with TTSR Compliance Officer. The topic of discussion was regulation 46(b) and how best to ensure that all DSPs and Individuals receive the Fire Safety within one year of previous training. TTSR has scheduled the Annual Fire Safety training for December 15th and 16th, 2025 (within the one year allotted timeframe from the last Fire Safety training which was held on January 9th and 10th, 2025). A memo was generated and sent to all locations to include the Administrative building to inform all TTSR Employees and Individuals residing of the need to attend this mandatory and annual training. For any staff or Individual that can not attend this two day mandatory training, arrangements must be made with TTSR Compliance Officer to schedule a time to receive this mandatory Fire Safety training before the one year timeframe allotted since last Fire Safety training. To ensure compliance, TTSR Compliance Officer is tasked with maintaining current staff rosters as well as Individual rosters and will review these rosters on a weekly basis until all DSPs and Individuals have received the required and mandatory training within one year of last training. By signing, TTSR Compliance Officer acknowledges that he has received a retrain on regulation 6400.46(b) and will ensure that he reviews staff and Individual rosters on a weekly basis until all DSPs and Individuals have received this required and mandatory training.	11/12/2025	Implemented
6400.52(a)(1)	Direct Service Worker #1's annual training, for the annual training year dated 1/1/24 through and including 12/31/24, contained 18.75 hours of training.	The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.	52(a)(1)- During licensing inspection on 10/29/2025, it was learned that Staff#1 did not maintain a record of trainings completed during the calendar year. This staff did not print or maintain any record of trainings completed during the 2025 calendar year nor did they do so during the 2024 calendar training year. On 10/30/2025, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director: 52(a)(1) -- The following shall complete 24 hours of training relating to job skills and knowledge each year: · Direct service workers, · Direct supervisors of direct service workers; and · Program specialists. Review of "Required 24 Hours of Training For All Staff and Supervisors" took place on 10/30/2025 (will be submitted for licensing review as an attachment). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. This document also assigns responsibilities of all staff and administrative staff when completing the training process (identified on attached document) Compliance will be measured through monthly In-Service Log reviews and any staff that need to complete mandatory trainings or complete trainings to meet the 24 hour requirement will be notified by TTSR Human Resource to ensure completion of required trainings for the calendar year.	10/29/2025	Implemented

SIN-00126899

Renewal

12/28/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.71	The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.	Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.	On 12/29/2017, an emergency contact sheet was obtained from the TTSR administrative office and was placed on the back of the telephone used in the common area. House supervisor will be tasked with making sure that emergency contact numbers remain on the phone or near the base of the phone used to make outside calls to remain in compliance with regulation 6400.71. During a meeting with house supervisor, Brooke Clinger held on 1/17/2018, a review of regulation 6400.71 took place and Brooke acknowledges (by signing the attached meeting signature page) that she will ensure that there are emergency contact phone numbers accessible and on the cordless phone itself and near the base of the charging station for the phone at all times through routine house inspections. TTSR Administrative staff will conduct random and routine house inspections throughout the year to see that all 6400 regulations are met in the home. Also attached is a photo of the phone that now has the emergency contact phone numbers attached to the phone. [Immediately and at least monthly, a designated staff person shall do an onsite check of all community homes to ensure telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line and are legible and up-to-date. Documentation of checks shall be kept. (AS 1/26/18)]	12/29/2017	Implemented

SIN-00071330

Renewal

11/05/2014

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.72(b)	The window screen in Individual #1's bedroom has a tear approximately 3 inches by 4 inches in the upper right hand corner.	Screens, windows and doors shall be in good repair.	The screen window was replaced on 11/5/2014 by TTSR Maintenence department (see attached photo)House supervisors were talked to on 11/20/2014 at a House Supervisors Meeting about the importance of routinely inspecting their homes on a weekly basis and to report any weathered screens for windows or doors to TTSR Administration through the use of the Supervisor Reports documents that identify needs in all homes of TTSR and are turned into the Administrative office on a weekly basis. House supervisors agreed to ensure that all screens are operable and were supportive of TTSR Administration continuing to conduct unannounced bi-monthly inspections of all homes. TTSR maintenance department will also routinely inspect homes when conducting other required and necessary maintenance in the homes to ensure compliance.	11/05/2014	Implemented
6400.112(c)	The fire drill records from October, 2013 to October, 2014 do not indicate problems encountered.	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 or smoke detector was operative.	On 11/6/2014, TTSR Secretary (Denise Babcock) met with Assistant Director, Matthew Gladin to discuss an area of non-compliance found during licensing inspection. The topic of discussion was the need for change on TTSR¿s ¿Fire System Check/ Fire Drill Report¿. Additions were made to the attached form which allows the staff responsible for conducting the fire drill to document ¿Problems encountered during the fire drill¿. If on the report, staff specify that there were problems encountered during the fire drill, staff are to document in detail what the problem was and how they will attempt to remedy the problem during future drills. Denise Babcock will be responsible for ensuring that on each fire drill received on a monthly basis, that the staff responsible for conducting the fire drills is successfully completing this section of the report to ensure follow up by appropriate TTSR Administrator. Changes were made to the Fire drill form on 11/4/2014 and was trained to Denise Babcock on 11/6/2014. Denise will talk to each house supervisor for each site to ensure that all are aware of these changes made to the form and to ensure that appropriate follow up occurs in the event that problems occurred during any fire drill. At a supervisor meeting held on 11/20/2014, all house supervisors were given the new form for fire drills and were given an explanation of the changes made to the fire drill form and how to properly ensure that the fire drill form should be completed in its entirety (signature page attached)	11/06/2014	Implemented
6400.112(f)	The monthly fire drill conducted from 10-30-13 to 10-12-14 used the front door exit.	Alternate exit routes shall be used during fire drills.	At a supervisor meeting held on 11/20/2014, all house supervisors were given the new form for fire drills and were given an explanation of the changes made to the fire drill form and how to properly ensure that the fire drill form should be completed in its entirety (signature page attached). It was also discussed that staff should switch exit routes from the previous fire drill to ensure that all individuals residing at the home know and can utilize all available escape routes in the home in the event of emergency or fire.	11/20/2014	Implemented
6400.186(b)	Individual #1 did not sign the three month review dated 4-28-14.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	On 11/25/2014, TTSR Assistant Director Matthew Gladin met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP as well as . The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1) Individuals will sign and date the ISP Review signature page upon review of the ISP. 2) Program Specialist will sign and date the ISP Review signature page upon review of the ISP. 3) Program Specialists will sign and date the most recent assessment for all individuals. By signing attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics and attest that they understand that these 3 steps must be done for all ISP reviews as well as for assessments prior to completion. As oversight, all of TTSR Administration, including Program Specialists will meet on a monthly basis to review any updates to any individual¿s ISP that was reviewed during the prior 30 day timeframe to ensure that all Administrative staff are made aware of important changes and to ensure that the signature pages contain the signatures of both the program Specialist as well as the individual. All assessments will brought to this meeting (if done during the prior month timeframe) to ensure that the assessment contains necessary signatures and dates.	11/25/2014	Implemented

SIN-00043544

Renewal

10/16/2012

Compliant - Finalized

SIN-00259124

Renewal

01/22/2025

Compliant - Finalized

SIN-00202186

Renewal

03/22/2022

Compliant - Finalized

SIN-00166531

Renewal

11/13/2019

Compliant - Finalized