Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286662 Renewal 04/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #3's record did not include a TB test prior to admission on 8/12/25.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The noted initial TB is uploaded to the one drive provided by the licensing inspector. There is also one completed after admission in the folder. 06/29/2026 Implemented
6400.141(c)(10)The annual physical dated 8/18/25 for Individual #3 did not indicate whether or not the individual was free of communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The corrected physical was uploaded day of inspection. 06/29/2026 Implemented
6400.141(c)(14)The annual physical dated 8/18/25 for Individual #3 did not indicate information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Annual physical is uploaded to the drive provided by our lead licensing inspector. 06/29/2026 Implemented
6400.34(a)Camera policy and consents were reviewed by and signed by a team member who is not legal guardian for Individual #3. There is no record of the policy and consent being reviewed with the individual informing them of the right to choose whether they want to have cameras in their home. There are currently cameras operating in the home. The signed forms also did not include the supported individual's name or home address on them.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.The camera consent has been completed appropriately and uploaded to the folder in the one drive provided by the Lead licensing inspector. 06/29/2026 Implemented
6400.169(d)Staff #3's current medication administration training documentation was incomplete.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The training records are uploaded to the one drive provided by the licensing inspector. 06/29/2026 Implemented
SIN-00061201 Renewal 02/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual # 1 had a late charge of $15 charged to her account from an invoice dated 3/15/13. The agency is the rep payee for this individual.(c) Individual funds and property shall be used for the individual's benefit. BH had a late fee charged to her account as a result of lack of insurance information provided to medical supplier for neubilizer. The length of time for proper follow-up caused the $15 late fee. Delta reimbursed BH for the $15 late fee. The copy of her financial general ledger will show that she was reimbursed on 3/19/14. Copy of ledger will be forwarded to your attention. On March 7, 2014 management staff were trained to ensure durable medical suppliers have all insurance information. This is documented on the March 7th Residential Mangers meeting agenda. A copy will be forwarded to your attention. The follow-up on insurance and medical needs is the responsibility of the project director. All consumer fund requests and medical bills will be reviewed by the Associate Director and Director prior to submission to fiscal to ensure proper insurance coverage/payment. 04/01/2014 Implemented
SIN-00123293 Renewal 08/01/2017 Compliant - Finalized