Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226508 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)(Repeated Violation -- 7/11/22) The self-assessment for the home completed on 11/4/22 did not include a written summary of corrections for the following regulations: 6400.46d, 6400.51b5, and 6400.165g.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
6400.216(a)The names of all the individuals residing in the home and their dates of birth were unlocked and accessible sitting next to the telephone in the hallway. An individual's records shall be kept locked when unattended. 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
SIN-00176445 Renewal 09/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The rear sliding glass doors leading to the deck do not have a light source.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Retraining was provided by Associate Directors of Operations to all Program Managers and Program Coordinators on the need for all areas of exterior walkways to be illuminated with electrical lighting. Retraining occurred on 9/4/2020. Lighting was immediately evaluated by Friendship Community Maintenance Team on 9/2/2020. Lighting was corrected by Maintenance Team Member on 9/15/2020. Exterior walkways shall be evaluated by all Program Managers to ensure all areas of walkways for each program are illuminated. This shall be completed by: 10/9/2020. Any areas of walkway that are not fully illuminated shall be immediately communicated to Friendship Community Maintenance Team and a work order shall be implemented. Friendship Community¿s Safety Committee shall monitor and review physical site checklists for programs, which includes review of exterior lighting of walkways. Any areas of concern shall be identified and appropriate work orders implemented to correct concern. 09/15/2020 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 9/01/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32The 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.Friendship Community¿s Individual Rights form, which is reviewed and signed by Individuals, shall be updated by Associate Director of Operations by 9/9/2020. Individual #1 shall be informed of all rights by the Program Manager and sign that he has been informed and understands all rights as outlined and updated per regulations by 10/9/2020. All Individuals shall be informed of all rights by Program Manager or designee and sign that they have been informed and understand all rights per regulation. This shall occur by 10/9/2020. Operations (Program Managers, Program Coordinators, Associate Directors of Operations) shall read and review all updated Individual Rights regulations and verify their understanding. This shall occur by: 10/9/2020. 10/09/2020 Implemented
SIN-00097570 Renewal 06/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The second drawer on the left side of Individual #1's dresser had a broken handle.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance Team Member fixed the dresser handle on 6/22/2016 which was the same day that it was discovered as broken. Each home will be inspected by the Program Manager, or designee, of the home to assure that all furniture is in good condition and repair. Utilizing Care Tracker, all Team Members (employees) will be trained on the necessity to assure that all furniture within the home is in good condition and repair. A designated Team Member will complete a quarterly physical site inspection at each location to ensure regulatory compliance. 10/31/2016 Implemented
6400.151(a)Staff #1's 2/24/15 physical exam was completed late. The previous physical exam was completed on 12/19/11. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Team Member has a current physical and TB Test on file. The lapse in compliance related to this Team Member¿s physical was discovered during the previous licensing inspection during an audit of all Team Member physical exam and TB dates as identified in the previous 6400 Plan of Correction. All Team Member records were reviewed by the Human Resources Department in an audit on 2/24/2015 to verify regulatory compliance. At that review, all Team Member records were updated to ensure regulatory compliance. A quarterly review of Team Member physical exam dates will occur to ensure regulatory compliance. 10/31/2016 Implemented
SIN-00245364 Renewal 05/30/2024 Compliant - Finalized
SIN-00076710 Renewal 02/18/2015 Compliant - Finalized