Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266378 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the home was tested and found to be 131.5 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature adjusted by Delta maintenance and new water temp at 116 degrees on 5/16/25 (attachment #13). 05/16/2025 Implemented
6400.101The sliding door in the dining room of the home was unable to be opened. Staff stated that it is due to be replaced in a week. Staff also stated that the door would be worked on to ensure it can open in case of an emergency. The door was fixed withing 24 hours.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Sliding door was fixed and the video was sent 5/16/25 (attachment #14) 05/16/2025 Implemented
SIN-00210934 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a section of countertop in kitchen that is not present. This area in the kitchen has no surface and leads directly into the drawers below. There is a broken dresser with multiple knobs and a drawer missing located in the spare bedroom. For the kitchen floor and the countertop work order requested by inspector but not provided.Floors, walls, ceilings and other surfaces shall be in good repair. Floor and counter tops were replaced by Delta maintenance on 9/16/2022 (Attachment #31, 32). The broken dresser was removed by 800GOTJUNK on 9/23/2022 (Attachment #33). 09/23/2022 Implemented
6400.67(b)There was a substantial amount of lint left in the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.Dryer lint was cleaned by residential coordinator on 8/31/2022 (Attachment #34). 08/31/2022 Implemented
SIN-00123298 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The first floor commom area has floor carpeting starting to acquire ridges which can cause a tripping hazard. The first floor staff room has exposed wires which should be in a metal box. Floors, walls, ceilings and other surfaces shall be free of hazards.The home is a rental property. There was a delay in replacing the carpet due to negotiating with the landlord. Delta has obtained a contractor and received an estimate to fix the carpet at an expense of $11,000 (Attachment #34). Carpet will be replaced with vinyl plank flooring on 12/21/17 and 12/22/17. The exposed wires have been covered and secured with an electrical box 8/14/2017 (Attachment #24) Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. 12/22/2017 Implemented
SIN-00091516 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff # 18's annual medication administration training dated 06/29/2015 was invalid as the third MAR review was completed on 09/09/2015 and fourth MAR review was completed on 12/06/2015.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
SIN-00224310 Renewal 05/09/2023 Compliant - Finalized
SIN-00061205 Renewal 02/18/2014 Compliant - Finalized