Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266366 Renewal 06/09/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)At the time of the inspection on 6/11/24, there was not an operable smoke detector in the attic. At the time of the inspection on 6/11/24, the smoke detector in the dining room was inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Inoperable smoke detector was replaced on 06/11/25 A smoke detector will be installed in the attic by 07/05/25 07/31/2025 Accepted
6400.112(a)A fire drill was not completed for October 2024. An unannounced fire drill shall be held at least once a month. Review that all fire drills were completed last year for all homes by 06/20/25. 07/31/2025 Accepted
6400.141(c)(3)Individual #1 is not current with immunizations, as the individual has not had the Tdap immunization since 5/3/12.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual is following up with Neurologist on 07/03/2025 to receive clearance to get their T-dap. 09/01/2025 Accepted
SIN-00245244 Renewal 06/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 has a fistula protocol in place indicating that the fistula site for dialysis must be checked for THRILL each morning. These checks were not conducted on the following dates: · September 21, 2023 · December 19, 23, 28, and 29, 2023 · January 10, 2024 · March 4, 2024Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Associate Director of Operations will train the team at Associate Director Sheephill Road on the importance of documenting individual medical protocols by 6/28/24. 08/30/2024 Implemented
6400.34(a)Individual #1's rights were reviewed with them on 4/29/23 and not again until 6/10/24, outside of the annual timeframe.The home 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 home and annually thereafter.Residential home had individual #1 to sign off on the correct individual rights document on 6/10/24. Associate Director of Operations will audit Friendship Community's shared drive to ensure that the old individual rights document archived from leadership team members to utilize by 7/12/24. 08/30/2024 Implemented
6400.166(a)(2)Individual #1's June 2024 Medication Administration Record did not include the correct prescriber for the following medications: Metoprolol, Oyster Shell, and Cal Gest.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Associate Director of Operations will train the team on the importance of initialing their initials when administrating individual's medication by 6/28/24. 08/30/2024 Implemented
6400.166(a)(10)There were no times listed for the following administrations of Calcium Acetate on Individual #1's Medication Administration Records: · November 26, 2023 · December 23, 24, and 27, 2023 lunch time administrations · December 17, 23, and 25, 2023 Dinner administrations · January 3, 13, 15, 18, 19, 20, 22, 24, 25, 27, and 28, 2024 dinner administrations · February 21, 2024, lunch time administrationA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Associate Director of Operations will train the team on the importance of listing medication times when administrating medications in the initials box by 6/28/24. 08/30/2024 Implemented
6400.166(a)(13)Individual #1's 8am dose of Risperidone and Omeprazole on 5/25/24 do not include the initials of the person administering the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Associate Director of Operations will train the team on the importance of initialing their initials when administrating individual's medication by 6/28/24. 08/30/2024 Implemented
SIN-00226520 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)(Repeated Violation -- 7/11/22) The self-assessment for the home completed on 11/2/22 did not include a written summary of corrections for 6400.151a.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
SIN-00191549 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill held in the month of December of 2020. An unannounced fire drill shall be held at least once a month. The Program Manager received immediate retraining on the need to complete successful unannounced fire drills once monthly on 8/13/21. Successful monthly drills have been documented since the violation occurred in December 2020, demonstrating a pattern of compliance. All Program Managers and Program Coordinators received retraining on 8/13/21 regarding the requirement to complete successful unannounced fire drills once monthly. 09/23/2021 Implemented
6400.112(c)The fire drill was held on 5/19/21, but the fire drill form was not created until 6/17/21 and then signed off by staff #1.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. All homes to complete an August 2021 fire drill, post Licensing, by August 25th and submit form within one hour of completing drill. Associate Director of Operations updated Friendship Community policy to require completion of Fire Drill Record within one hour of completing the drill, and provide training on updated expectations to Program Managers and Program Coordinators on 8/20/21. 09/23/2021 Implemented
6400.213(1)(i)Individual #1 does not have a current dated photo. The photo in the record is dated 6/21/17.Each individual's record must include the following information: current dated photoIndividuals face sheet was immediately updated to include a current photograph on 8/13/21. Program Specialists shall conduct an audit of all individuals photographs and face sheets and update accordingly by 10/31/21. Associate Director of Operations shall provide retraining to Program Managers, Program Coordinators, and Program Specialist of requirement to update all individuals photographs annually. 09/23/2021 Implemented
SIN-00176449 Renewal 09/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.212(a)Individual #2 November 2019 cash receipts were included in Individual #1 financial information during the review. A separate record shall be kept for each individual. Individual #1¿s and Individual #2¿s incorrectly filed receipts were immediately filed within the correct Individual¿s records. Immediate retraining was provided to Finance Associate by Associate Director of Operations on 9/4/2020 regarding the need to maintain separate records for each Individual. Finance Associate shall complete a financial audit of all Individuals who have an identical first or last name, and ensure all receipts are filed correctly, within the appropriate Individual¿s file. Documentation of this audit shall be provided to Associate Director of Operations and maintained on file. This shall be completed by 10/31/20. Finance Associate shall revise departmental policy to ensure immediate filing of receipts in the correct individual¿s record, to include systems to more easily distinguish between Individuals who have the same first or last name. This policy shall be developed and implemented by 10/9/2020. 09/04/2020 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 9/01/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32.The home 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 home and annually thereafter.Friendship Community¿s Individual Rights form, which is reviewed and signed by Individuals, shall be updated by Associate Director of Operations by 9/9/2020. Individual #1 shall be informed of all rights by the Program Manager and sign that he has been informed and understands all rights as outlined and updated per regulations by 10/9/2020. All Individuals shall be informed of all rights by Program Manager or designee and sign that they have been informed and understand all rights per regulation. This shall occur by 10/9/2020. Operations (Program Managers, Program Coordinators, Associate Directors of Operations) shall read and review all updated Individual Rights regulations and verify their understanding. This shall occur by: 10/9/2020. 10/09/2020 Implemented
SIN-00119254 Renewal 07/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(e)REPEAT from 6/20/16 renewal inspection: Staff #1 was hired on 1/18/17 and she did not receive training on program planning and implementation and normalization until 3/23/17, more than 30 days passed her date of hire. Program specialists and direct service workers shall have training in the areas of Intellectual Disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Immediate: Team Member (Staff) #1 received orientation to program planning and normalization on 3/23/2017. The Training Team responsible for ensuring orientation occurs within 30 days, including program planning and normalization, was verbally retrained on or before 7/21/17 by the Director of Operations. The Training Team Members shall receive documentation of this retraining on or before 9/15/17 by an Associate Director of Operations and each member shall acknowledge their responsibility in ensuring orientations occur with in the first 30 days of employment for each Team Member. Global Immediate: A training file audit of all Team Members hired within the last year shall be conducted by the facility¿s Orientation/Training Administrator or designee on or before 10/15/17. As applicable, any identified areas of non-compliance shall be addressed within 5 business days following discovery by a member an Associate Director of Operations or designee. Global Preventive: Friendship Community¿s training plan shall address regulatory compliance with Team Member training responsibilities and expectations, including disciplinary action steps for instances of non-compliance. The Associate Director of Operations shall ensure that all Team Members acknowledge their awareness of training requirements and their responsibility to adhere to all training expectations on or before 10/15/17. 10/31/2017 Implemented
6400.67(a)Individual #1's bedroom door that opens to the outside of the home, would not open unless licenser pushed hard and leaned into the door. Floors, walls, ceilings and other surfaces shall be in good repair. Immediate: The door located in the Individual #1¿s bedroom was adjusted to ensure safety and good repair on 7/17/17 by a member of the Maintenance Team. Global Immediate: Program Managers shall be instructed by a Program Coordinator on or before 8/22/17 to perform a physical site review to identify any floors, walls, ceilings and other surfaces that may need to be repaired at each physical site, with the expectation to communicate all repair needs to the Maintenance Team on or before 9/15/17. Global Preventive: A Program Coordinator shall retrain Program Managers on or before 8/22/17 regarding the requirement to ensure that all floors, walls, ceilings and other surfaces are maintained in good repair, including the expectation that any needed repairs noted to surfaces are requested of the Maintenance Team immediately upon discovery. 10/31/2017 Implemented
6400.68(b)The water temperature in the home was 123.8 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Immediate: On 7/17/17, the Program Manager received confirmation that a member of the Maintenance Team adjusted the water temperature to ensure that it did not exceed 120 degrees Fahrenheit. Global Immediate: New thermometers shall be purchased for use by each Program Coordinator and distributed on or before 8/28/17 to ensure accurate and consistent readings within each facility. Each Program Coordinator shall compare readings from new and existing thermometers at each facility on or before 9/30/17, ensuring that any water temperature concerns are addressed immediately by communicating the need to adjust water temperature to the Maintenance Team. Any discrepancies noted between thermometers shall be addressed by replacing the inaccurate thermometer. Global Preventative: Associate Director of Operations shall provide retraining to Program Coordinators on or before 8/28/17 regarding the requirement to check and record water temperatures during each calendar month¿s monitoring, alternating water sources each month. As applicable, Program Coordinators shall document any water temperature concerns noted and actions taken to address concerns, including the outcome, on the monthly monitoring form. 10/31/2017 Implemented
6400.104The 6/21/17 letter sent to the fire department indicated that all individuals residing in the home could evacuate the home independently. However Individual #1 requires verbal and physical assistance according to the fire drill log and staff in the home. Another letter was not sent to the fire department after 6/21/17 to indicated the bedroom of Individual #1 who required assistance. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Immediate: The Program Manager updated Individual #1¿s evacuation needs in a letter to the fire chief on 7/14/17 and mailed the letter to the fire chief in adherence with the expectation to 1) notify the local fire department in writing of the address of the home and the exact location of the bedrooms of Individuals who need assistance evacuating in the event of an actual fire, and 2) the expectation to keep documentation of the notification current and on file within the facility. Global Immediate: The Program Coordinators shall receive retraining by an Associate Director of Operations on or before 8/28/17 regarding the expectation to 1) notify the local fire department in writing of the address of the home and the exact location of the bedrooms of Individuals who need assistance evacuating in the event of an actual fire, and 2) the expectation to keep documentation of the notification current and on file within the facility. Global Preventive: Program Coordinators shall review each facility¿s fire/emergency response records during each calendar month¿s monitoring and verify notification to the local fire department is current and on file. 10/31/2017 Implemented
SIN-00245376 Renewal 05/30/2024 Compliant - Finalized
SIN-00061189 Renewal 02/12/2014 Compliant - Finalized