Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262491 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 3/12/2025 at 12:02PM, there was no screen in the only window in Individual #1's bedroom. On 3/12/2025 at 12:04PM, there was no screen in the window by the bed in Individual #2's bedroom. On 3/12/2025 at 12:05PM, there was no screen in the window next to the bed in Individual #3's bedroom.Windows, including windows in doors, shall be securely screened when windows or doors are open. The facility has already installed all screens in all windows of the individual # 1, #2, #3¿s bedrooms. In addition, the maintenance Manager will be in-serviced on making sure that all windows in every house are checked to ensure that every window that opens has a screen to prevent future similar deficiencies. This in-service will be completed by 04/15/2025. This process will be monitored by the facility COO every six months to ensure compliance and prevent repetition in the future. 03/28/2025 Implemented
6400.101On 3/12/2025 at 1:09PM, there was a hook and eye lock attached to the inside of the door leading to the bathroom in the basement of the home. On 3/12/2025 at 1:15PM, there was keyed locking mechanism on the garage side of the door in the basement leading to the garage causing a blocked egress when engaged. There is no swing door inside the garage of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The facility has already removed the hook and eye lock that was attached to the inside of the door leading to the bathroom in the basement of the Anita home. Also, the locking mechanism on the garage side of the door in the basement leading to the garage causing blocked egress was removed and replaced with the keyless doorknob, so it cannot be locked. in addition, an in-service will be given to maintenance manager on making sure that hook and eye lock and basement doors leading to the garage doors in every house have keyless locking mechanism to facilitate passageways and exits from rooms and from the building without any obstructions. This in-service will be completed by 04/15/2025, This process will be monitored by the facility COO every six months to ensure compliance and prevent any future similar deficiencies. 03/28/2025 Implemented
6400.32(r)(1)On 3/12/2025 at 12:01PM, there was a keyed locking mechanism on the door leading to Individual #1's bedroom. Staff interviews revealed that Individual #1 is not able to use a key to lock and unlock the door independently.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.The program specialist has already assessed individual #1 and is not able to keep, carry, or hold a key to use to lock or unlock their bedroom or home doors independently. The individuals¿ SCs and family/representative/ legal guardian were all informed by email about these individuals¿ assessments. In addition, all locks will be replaced by our maintenance with locks that do not have a locking mechanism. Furthermore, an-in-service to all program specialists will be issued to make sure all homes and individuals are assessed, and proper key mechanisms are implemented to prevent future similar deficiencies. This in- service will be completed by 04/15/2025. Moreover, this process will be monitored by the Program Specialist Mangers quarterly and the resident services director bi-annually to make sure all individuals are assessed, and all locking mechanisms are installed appropriately to prevent and ensure compliance. 03/28/2025 Implemented
SIN-00241321 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace in the home was inspected and cleaned by a professional furnace cleaning company on 12/02/22, and then again on 02/20/24. This exceeds the annual requirement.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Facility will ensure all furnaces shall be inspected and cleaned at least annually by an external professional furnace cleaning company regardless of the house being empty with no individuals at the time of furnace inspection is due. An in-service is given to the Maintenance Manager to make sure all furnaces are inspected yearly by coordinating the inspections with external professional company to be completed 2 months before the end of the year to ensure compliance. This in-service was completed on 03/24/2024. In addition, all inspected furnace documents are to be submitted to the resident services director for review two months before the end of the year to ensure compliance. The Sr. residential director will monitor that this process is followed, and all documents are in good order and are accounted for one month before the end of the year to ensure compliance and prevent similar future incidents. 03/24/2024 Implemented
6400.112(f)Fire drills conducted from 04/01/23 through and including 09/22/23 utilized the front/door main entrance as the exit for all drills. The home has more than one exit.Alternate exit routes shall be used during fire drills. The facility has already in-serviced the house Manager and the program Specialist on making sure that they are using alternate exit routes when conducting fire drills. In addition to the in-service, the program specialist manager will review the fire drills each month to ensure that alternate exit routes are used when possible. The resident services director will monitor this process by checking fire drills quarterly to ensure compliance and prevent future similar incidents. It should be noted that this deficiency should be cited for the following reasons: 1. The individual who lived in this house from April 2023 to October 2023 could not do steps; he uses walker/ wheelchair to ambulate with staff assistance. 2. It is also documented in his ISP. 3. HRST also states the same thing, using a walker with staff assistance and should not use steps. 4. 6400.102 states that ¿if four individuals sleep above the ground floor, there shall be a minimum of two interior or exterior exits from each floor¿. In Clover house where we received the deficiency, there is only one main exit that the individual who lived there could use safely since he could not do step. The other exit has deep narrowed steps, and that is the reason why we did not use the second exit as an alternate. I mentioned 6400.102 because it did not mention that you have to have two exits if you have 3 or less individuals living in the house. We are aware that we need to alternate exits when conducting fire drills. I was pointing out that if you have only when safe exit, how can you alternate? 03/27/2024 Implemented
SIN-00070566 Renewal 10/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The outside dryer vent had a ¼ inch thick layer of lint lining the inside of the vent and a handful of lint was removed from inside the vent. Furniture and equipment shall be nonhazardous, clean and sturdy. The facility will ensure that furniture and equipment shall be nonhazardous, clean and sturdy. Maintenance Staff will make sure that dryer lint will be pulled and cleaned from the inside and outside dryer vent. All maintenance staff will be in-serviced on cleaning and documenting that the dryer vents in every house are cleaned once a month in order to prevent reoccurrence in the future. [The dryer ductwork has been cleaned. (CHG 11/18/14)] 11/08/2014 Implemented
SIN-00203181 Renewal 04/05/2022 Compliant - Finalized
SIN-00144222 Renewal 10/23/2018 Compliant - Finalized
SIN-00103775 Renewal 11/16/2016 Compliant - Finalized