Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226507 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 10/14/22 did not assess compliance with the following regulations: 6400.19a2 -- 6400.19a5, 6400.24, 6400.21a -- 6400.32s2, 6400.32u-6400.33b, 6400.45a -- 6400.45e, and 6400.162c1 -- 6400.162c6.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation - 7/11/22) The self-assessment for the home completed on 10/14/22 did not include a written summary of corrections for 6400.46d.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-00097569 Renewal 06/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(e)Staff #1 was hired on 5/16/15 and was not trained on rights until 12/17/15.Program specialists and direct service workers shall have training in the areas of mental retardation, 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. Team Member # 1 had received Individual¿s Rights training on 12/7/2015; due to this being a timely regulation, no further immediate corrective action can occur. On 6/22/2016, a `Team Member Acknowledgement of Individual `s Rights¿ form was created and immediately was implemented as an initial orientation training practice that occurs for all Team Members on their first day of initial employment. Initial orientation training designee obtained signatures for each employee who attended initial orientation since 5/22/2016 on the `Team Member Acknowledgement of Individual¿s Rights¿ form to ensure regulatory compliance for those Team Members. Acknowledgement of Individual `s Rights form will continue to be incorporated into the initial orientation training and reviewed with new hired Team Members within the first 30 days of employment. 10/31/2016 Implemented
SIN-00266354 Renewal 06/09/2025 Compliant - Finalized
SIN-00245363 Renewal 05/30/2024 Compliant - Finalized
SIN-00207952 Renewal 07/11/2022 Compliant - Finalized
SIN-00157449 Renewal 08/13/2019 Compliant - Finalized