Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264347 Renewal 03/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At the time of the 03/25/25 inspection, there was a spray bottle of Clorox Cleaner and Bleach under the unlocked cabinet in the bathroom. All poisons must be locked in this home for Individual safety.Poisonous materials shall be kept locked or made inaccessible to individuals. This occurred due to a lack of training on the necessity of keeping poisonous materials locked in this specific program after use. Staff failed to return supplies to the locked location after cleaning the bathroom. Immediately upon discovery, the poisonous materials were locked. Re-education was provided on 3/27/2025 to program staff by management. 05/30/2025 Implemented
SIN-00210998 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the 8/31/22 inspection, the hallway flooring planks were separating from each other in a few locations, creating gaps in the locations that it was separating.Floors, walls, ceilings and other surfaces shall be in good repair. There was a maintenance request submitted immediately and maintenance was out to assess. Maintenance has reached out to the landlord to discuss replacing or renovating the floor. 09/25/2022 Implemented
SIN-00198479 Renewal 01/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)(Repeat from inspection dated 1/11/21) No self-assessment was completed for this home.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. Staff will be trained on how to complete the Self-Assessment form thoroughly. 02/28/2022 Implemented
6400.64(a)At the time of the inspection, there was a nonfunctional washing machine in the garage that was filled with plastic shopping bags and cloth.Clean and sanitary conditions shall be maintained in the home. Washing machine has been removed from the garage. 02/28/2022 Implemented
6400.67(a)At the time of the inspection, there was a black substance at the base of the shower stall.Floors, walls, ceilings and other surfaces shall be in good repair. Black substance was cleaned, company came to recaulk the shower, staff was educated on new documentation and maintenance request process. 02/28/2022 Implemented
6400.103(Repeat from inspection dated 1/11/21)-The written evacuation procedure does not include a specific location to be used as an emergency shelter in the even the home becomes inhabitable. The written plan speaks to locations as "nearest hotel," "with relative," "local hotel," "another TLC employee home," "another TLC home," but does not identify the specific location to be used.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. TLC is recreating a written evacuation procedure plan based on the 6400.103 regulation and will be updating all evacuation plans. 02/28/2022 Implemented
6400.112(a)(Repeat from inspections dated: 1/11/21, 5/10/21, and 10/12/21- According to the fire drill record for the fire drill held in August 2021 (8/12/21), the drill was identified as an announced drill indicating all participants were aware the fire drill was about to be conducted. An unannounced fire drill shall be held at least once a month. Training on Fire Drill Requirements have been provided to all staff. Quality Department will utilize the Fire Drill Log form which was updated to determine which homes have not completed fire drills and send email to Program Specialist, Program Manager, and Director of Residential to inform them of which homes need to be completed. 02/28/2022 Implemented
6400.113(a)(Repeat from inspection dated 5/10/21) There were no records provided that Individual #1 received general fire safety training, defined in 6400.113(a), annually. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The form is completed, and it has been placed in AWARDS under "Fire Safety Training." 02/28/2022 Not Implemented
SIN-00181503 Renewal 01/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)REPEAT VIOLATION FROM 12/10/19: The self-assessment for this home is undated, so it is unclear when it was completed.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. A self-assessment is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/finidings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. 03/05/2021 Implemented
SIN-00167432 Renewal 12/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)The bathroom off of individual #1 room had a shower that did not contain a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Non skid bathmat was placed into the shower of the bathroom of Individual #1. Program manager accomplished this task within an hour of the licensing inspection when citation was found. See Attachment #82(e) Picture of bathmat. Program Managers under the supervision of the appropriate ADOS-Operational will, monthly look for and assure Bathtubs and showers have a nonslip surface or mat.. All Residential Program Managers will be retrained on the Monthly Physical Site and Fire Safety Checklist to ensure Bathtubs and showers have a nonslip surface or mat.. See Attachment #68(b) Monthly Physical Site and Fire Safety Checklist. See Attachment Training Log 165(c). 03/01/2020 Implemented
6400.106Furnace inspection completed 9/21/18 and not again until 10/25/19.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. Nothing immediate was needed, since the furnace inspection already took place. The 15 day grace period makes it much easier to perform furnace inspections when they should be done, which is the beginning of he heating season. Each 2019 inspection has been entered into a spreadsheet and will be shared with the HVAC inspection company in 2020. The Director of Properties and Purchasing will work closely with the HVAC company to ensure the inspection and cleaning is done in the required time frame.See Attachment #106. 01/31/2020 Implemented
6400.141(c)(14)Individual #1 most recent physical dated 10/25/19 has a space for "info pertinent to diagnosis in case of emergency" but it was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Manager will be responsible to ensure the Physical Form is corrected and submitted to PCP to be signed and dated. This will be completed by January 31, 2020. PM will attend the physical appointment in every case. In the case of a PM not being available to attend the Physical appointment another Program Manager or ADOS will attend the appointment. It will be the responsibility of the Operational ADOS's to train all Program Managers in the expectations of the physical exam process. This will be completed by February 29, 2020.See Attachment Training Log 165(c)(14). 03/01/2020 Implemented
6400.165(c)Individual #1 medication Fluticasone (generic for Flonase) 50 mcg nasal medication states on the Medication administration record (MAR) "2 Sprays into each nostril" however the directions on the medication label state, "use 1 spray into each nostril once daily".A prescription medication shall be administered as prescribed.Program Manager called physician upon notification of citation to verify dosage of Fluticasone (generic for Flonase). Dosage was incorrect on the label. New script sent to pharmacy and new script with correct dosage of "2 sprays" was received the following day. Immediate reminder of the 6 Rights in the process for Medication Administration. Responsible party is the Program Manager with assistance as needed by the Clinical ADOS. Retraining for Butter staff by January 31, 2020. Retraining of all Residential staff in the 6 Rights of medication administration. Professional medical staff, (RN and LPN) will retrain ADOS' and Program Managers by the end of January 2020. Program Managers will train their direct care staff by 2/29/2020. Quality staff will randomly audit at least 3 program locations on a monthly basis assuring medications are given properly beginning February 1, 2020.See Attachment Training Log 165(c). 03/01/2020 Implemented
SIN-00261748 Renewal 03/24/2025 Compliant - Finalized
SIN-00241375 Renewal 04/01/2024 Compliant - Finalized