Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245931 Renewal 06/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65Basement bathroom has no proper ventilation, the window is blocked by an outside cover not allowing ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On Thursday June 5, 2024, a maintenance request was submitted through our Worxhub computer maintenance system by the Residential Coordinator to evaluate the basement bathroom to ensure proper ventilation. The maintenance Director ordered materials to correct the ventilation in the basement bathroom and will be completed by 8/30/2024. 08/30/2024 Implemented
6400.67(a)Bathroom #2 window is damaged and won't stay open.Floors, walls, ceilings and other surfaces shall be in good repair. On Thursday June 5, 2024, a maintenance request was submitted through our Worxhub computer maintenance system by the Residential Coordinator to fix the window in Bathroom #2. The work was completed on 6/6/2025. 06/06/2024 Implemented
SIN-00120224 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(b)TYLENOL AND IBUPROFEN PACKETS WERE FOUND IN THE FIRST AID KIT WHICH WAS UNLOCKED ON TOP OF THE REFRIGERATOR IN THE KITCHEN. Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. Tylenol and Ibuprofen packets were removed from the first aid kit at the home on 8/15/2017 and disposed of. Going forward all prescription and potentially toxic non prescription medication is locked in the medication cabinet of the facility (home) unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. The House Manager of each facility performs monthly home checks to ensure each area of the home is safe and free of hazards. Checking the first aid kit has been added to these home checks. The Home checks are forwarded to the Residential Coordinator for review. The Residential Coordinator will report any areas of the home that are non compliant to the Director of Operations. The Director of Operations will ensure a plan of correction occurs immediately and the area of the home is safe and free of hazards. 09/30/2017 Implemented
6400.167(b)THE MEDICATION BENSOTROPINE WAS PRESCRIBED FOR INDIVIDUAL #1 TO BE TAKEN AT MORNING AND AT BEDTIME. THE MAR INDICATED THAT THE MEDICATION WAS BEING ADMINISTERED AT 8 AM AND AT 5 PM. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The Health care Coordinator reviewed Individual #1's physician order for Bensotropine on 8/16/2017. She corrected the time to be administered on the Medication Administration Record (MAR) to correct the time to be given according to the physician's order. Going forward the follow procedure was put into place and the CLA Management team was trained on 9/18/2017. A routine medication/new medication (PRN or routine) is prescribed by a physician, the script is sent to the pharmacy to be filled. Upon receipt of the new medication, the Health Care Coordinator, when possible/or a medication administration certified staff will transcribe the medication onto the medication administration record (MAR) exactly as prescribed according to the pharmacy label (including the 5 rights; Individual, Time, Dosage, Route and Medication). The self-medication certified staff every shift ensure the medications as prescribed on the MAR are located in the residence for the individual. Any discrepancies are reported to the House Manager (HM) of the facility. The House Manager will perform a check of all medications prescribed on the MAR to the actual medications in the home weekly. The Residential Coordinator of the facility will perform a random check, 2 home checks per month to ensure medications prescribed on the MAR to actual medications in the home (routine and PRN medications. The consulting Pharmacist performs medication checks on a quarterly basis and sends report to the Director of Nursing of the facility. 09/18/2017 Implemented
SIN-00091925 Renewal 04/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(14)Individual #5¿s annual assessment dated 8/05/15 did not document their ability to swim. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. In Individual #5's Recreation assessment dated 8/5/2015 indicated his inability to swim. Effective 7/1/2016 a new assessment was initiated and the individuals knowledge of water safety and ability to swim is addressed in this document that will be updated yearly with the ISP by the Program Specialist. 07/01/2016 Implemented
SIN-00268487 Renewal 06/10/2025 Compliant - Finalized
SIN-00225312 Renewal 05/23/2023 Compliant - Finalized
SIN-00162728 Renewal 09/17/2019 Compliant - Finalized
SIN-00075326 Renewal 03/30/2015 Compliant - Finalized
SIN-00061591 Renewal 03/13/2014 Compliant - Finalized