Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242917 Renewal 04/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The fire safety inspections conducted 12/13/2022 and then again 7/14/2023 did not include documentation of the results.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The agency reached out to the landlord and requested documentation of fire safety results. The fire safety results were not able to be produced, only dates, therefore the landlord has rescheduled a fire safety inspection to take place on May 6, 2024, which will produce an updated thorough inspection of the premises as well as all necessary documentation. 05/06/2024 Implemented
2380.111(c)(1)Individual #4's physical examination, completed 8/28/2023, did not include a review of previous medical history. It stated it was not applicable.The physical examination shall include: A review of previous medical history.On 4/26/2024, The Program Specialist will send home a letter requesting previous medical history to be sent to the Program so that it can be attached to the 8/28/23 physical. 04/26/2024 Implemented
2380.111(c)(4)Individual #1's physical examination completed 11/01/2023 did not include a hearing screening. Individual #2's physical examination completed 9/06/2023, states the individual had some cerumen and does not indicate their ability to hear. There was no documentation of a follow-up since.The physical examination shall include: Vision and hearing screening, as recommended by the physician.On 4/26/24, a copy of individual #1 physical will be returned to her caregiver. The Program Specialist will request that an examination of her hearing be completed immediately. On 4/26/24, a copy of individual #2 physical will be sent home, and the Program Specialist will request that physical form is returned to the physician and follow up is completed on hearing exam. 04/26/2024 Implemented
2380.173(1)(iv)Individual #1's, individual #2's, Individual #3's, and individual #4's record did not include religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.On 4/18/24, the Program Specialist updated and filled out all emergency forms to include accurate responses for Religious Affiliation. Starting 4/26/24, the Program Specialist will also review all other charts to ensure that this is accurately filled out for all individuals. 04/18/2024 Implemented
2380.174(b)Individual #1's, Individual #2's, Individual #3's, and Individual #4's records did not include the most current copy of the individuals' support plans.The most current copies of record information required in §  2380.173(2)¿(11) shall be kept at the facility.On 4/25/24, The Program Specialist printed off all current copies of ISP¿s for all program participants. The staff members are actively being trained on these updated ISP¿s. The Program Specialist has been retrained on ISP regulations and requirements as of 4/16/24. 04/16/2024 Implemented
2380.181(e)(10)Individual #2's assessment, completed 12/14/2023, did not include a lifetime medical history. Individual #3's assessment, completed 8/16/2023, did not include a lifetime medical history. Individual #4's assessment, completed 12/14/2023, does not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.A review of all individual charts has been completed as of 4/26/24 to ensure that all charts contain lifetime medical history. If it does not, the Program Specialist will begin taking steps to add lifetime medical history to their file. 04/26/2024 Implemented
2380.21(u)Individual #2 was informed of individual rights and the process to report a rights violation 10/11/2022 and not again since.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 rights form was sent home on 4/23/24 for the individuals guardian to fill out with him. 04/26/2024 Implemented
2380.182(c)Individual #2's individual support plan, last updated 4/05/2024, states the individual take his noon time Depakote independently with his lunch while at day program. The individual does not have any medication administered during the program. Individual #3's assessment completed 8/16/2023, states the individual is independent in using and avoiding poisonous substances. Individual #3's individual support plan, last updated 6/09/2023, states the individual needs supervision to use poisonous substances. Individual #4's assessment, completed 12/14/2023, states the individual is independent in avoiding and using poisonous substances and avoiding heat sources. Individual #1's individual support plan, last updated 12/20/2023, states the individual does not demonstrate an understanding that chemicals can be poisonous and is unable to be around heat sources.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 4/26/24, The Program Specialist requested team meetings to discuss individuals' abilities/supervision requirements. Following the meeting, and whatever is decided at the meeting, the Program Specialist will request that the ISP be updated, or a clause specific to day program be added. 04/26/2024 Implemented
SIN-00205242 New Provider Agency 05/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)During the inspection completed 5/18/2022 the following poisonous materials were identified unlocked and accessible in the kitchen area: 1 gallon bottle of Clorox Disinfecting Bleach and a 32oz. spray bottle of Multi-Surface Cleaner, with instructions to contact poison control or a doctor for further treatment advice.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.At this time this has been corrected. We reminded those who manage the building in which we rent that poisonous material needs to be locked. Since the poisonous materials that were identified were not ours, they indicated they will keep them locked. I will email a photo of the area that had poisonous material to show that there is no longer poisonous material in that location. 05/27/2022 Implemented
2380.59(b)During the inspection completed 5/18/2022 the hot water temperature measured 124.3°F at the sink in the kitchen to the left of the entrance.Hot water temperatures in areas accessible to individuals may not exceed 120°F.At this time this has been corrected. The hot water tank was adjusted, and temperatures were taken at multiple sinks to ensure the water temperatures were reading below 120*F. I will email an image and video of the temperature readings. 05/27/2022 Implemented
2380.82During the inspection completed 5/18/2022 there were two closets identified in the program room with, padlocks on them, and big enough for an individual to fit inside.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.At this time this has been corrected. I asked permission of the management of the space from which we rent if I could change the way in which those two closets were locked. They agreed to the change. I purchased and installed locking doorknobs that can lock from the outside and open from the inside. I will email images to show that the padlocks, along with the latch, have been removed. I will also include an image of one of the knobs installed. 05/27/2022 Implemented
SIN-00264626 Renewal 04/15/2025 Compliant - Finalized
SIN-00224016 Renewal 05/04/2023 Compliant - Finalized