Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270945 Renewal 07/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 7/30/25, at 10:38 AM, there was no lighting fixture or sufficient nearby light source located outside of the basement exterior door on the side of the home across from the driveway.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On July 31, 2025 Community Living and Learning Maintenance Person added a light fixture to the basement exterior door, ensuring there is proper lighting to assure safety and avoiding accidents. The 6400 Supervisors and Program Directors were trained on August 7,2025 on Lighting 6400.66 in the Regulatory Compliance Guide Chapter 6400. 07/31/2025 Implemented
6400.72(b)At 10:42 AM on 7/30/25, the mesh along the handle of the exterior sliding glass screen door leading from an open office area to the side of the home was torn in a linear fashion, measuring 2.5 inches in length. Screens, windows and doors shall be in good repair. On July 31, 2025 Community Living and Learning Maintenance Person removed the screen to the sliding glass door. The 6400 Supervisors and Program Directors were trained on Screens, Windows, and Doors 6400.72 in the Regulatory Compliance Guide Chapter 6400 on August 7, 2025. 07/31/2025 Implemented
6400.81(h)On 7/30/25, at 10:18 AM, the only window in Individual #3's bedroom was covered with a plastic frosting adhesive that prevents a view of the outside.Each bedroom shall have at least one exterior window that permits a view of the outside. On July 31, 2025 Community Living and Learnings Maintenance Person removed the plastic frosting adhesive from the individual¿s bedroom window, ensuring the individual has a view to the outside. The 6400 Supervisors and Program Directors trained on 6400.81(h); Individual Bedrooms in the Regulatory Compliance Guide Chapter 6400. 07/31/2025 Implemented
6400.181(e)(1)Individual #1's current assessment, completed on 9/10/24, did not address their preferences, as there was no corresponding field or relative content. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The Program Specialist did an addendum to the Individuals assessment (9-10-24) on 08-01-2025 to include the Individuals Preferences. The Program Specialist completed an online training in the Relias Platform entitled ¿Assessments in IDD¿ on August 5,2025. 08/01/2025 Implemented
6400.52(c)(5)Direct Service Provider #1 did not complete annual training for the 2024 calendar annual training year regarding individual-specific reviews of Individual #2's behavior support plan and Individual #1's restrictive procedure plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The DSP was trained on the individual #1 Behavioral support plan and Individual #2 Restrictive procedure plan and Behavioral support plan on 08-04-2025. 08/04/2025 Implemented
SIN-00232347 Renewal 09/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1's individual service plan, last updated 6/09/2023 states, "In an academic setting the individual requires assistance with evacuation, if the smoke alarm sounds, others might need to carry him out for the sake of speed." Individual #1's assessment completed 5/01/2023 states the individual is able to evacuate in 2 ½ minutes, with verbal prompting and was sent to the plan team members on 5/01/2023.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Executive Director contacted the SC supervisor Bobbie Thom to alert the supports coordinator to their role , along with Community Living & Learning to make sure the annual ISP and assessments reflect current and updated information. Supports coordinator Jayde Hanjos updated Individual # 1'a ISP plan to reflect the assessments information that the individual does not need physical assistance during a fire evacuation. The supports coordinator and Community Living & Learning Program Specialist and other team members will hold a meeting from now on when an individual's assessment is due. The meeting will ensure all team members are sharing correct information and that the information is reflected correctly in the individuals ISP and assessment both. 10/18/2023 Implemented
SIN-00141669 Renewal 08/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(12)Individual #1's assessment completed on 2/12/18, did not include recommendation for specific areas of training, programming and services. This section had "none at this time" entered.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The failure to indicate specific areas of training, programming and services was an oversight on the Program Director's part. This individual's assessment has been revised to include specific areas of training, programming, and services. Community Living & Learning has taken two steps to prevent recurrence with this issue. Community Living & Learning has revised the agency assessment and provided training to management on the completing the assessment. The Executive Director will review each assessment completed over the next year to ensure all assessments are being done correctly. The Executive Director will sign on the assessment to indicate it was reviewed. [Documentation of aforementioned training at a "supervisor meeting" on 8/28/18 submitted to the Department. Immediately, upon hire and continuing at least annually, the Executive Director shall educate the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and the requirements of individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and continuing at least quarterly, the program specialist shall audit all individuals' current assessment to ensure all required information is included and update as needed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/20/18)] 09/19/2018 Implemented
6400.181(e)(14)Individual #1's assessment completed on 2/12/18 did not include individual's knowledge of water safety and ability to swim. This section was left blank.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. The failure to indicate individual's knowledge of water safety and ability to swim was an oversight on the Program Director's part. This individual's assessment has been revised to include the individual's knowledge of water safety and ability to swim. Community Living & Learning has taken two steps to prevent recurrence with this issue. Community Living & Learning has revised the agency assessment and provided training to management on the completing the assessment. The Executive Director will review each assessment completed over the next year to ensure all assessments are being done correctly. The Executive Director will sign on the assessment to indicate it was reviewed.[Documentation of aforementioned training at a "supervisor meeting" on 8/28/18 submitted to the Department. Immediately, upon hire and continuing at least annually, the Executive Director shall educate the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and the requirements of individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and continuing at least quarterly, the program specialist shall audit all individuals' current assessment to ensure all required information is included and update as needed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/20/18)] 09/19/2018 Implemented
SIN-00082972 Renewal 08/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest hospital and ambulance were not on or by the telephone located in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. A new posting was put up the same day beside all of the phones in the home. The new posting included the nearest hospital, police department, fire department, ambulance, and poison control center. Also added to the Supervisor Site Visit Checklist was checking that these emergency numbers are present and include the poison control center.[Within 1 month of receipt of the plan of correction, aforementioned site visit checklist will be completed at least monthly and reviewed at least quarterly by the CEO to ensure completion and that all required telephone numbers are on or by all telephones with an outside line. Documentation of checklists and reviews shall be kept. (AS 3/2/16)] 08/20/2015 Implemented
SIN-00212273 Renewal 09/28/2022 Compliant - Finalized
SIN-00196015 Renewal 11/09/2021 Compliant - Finalized
SIN-00179974 Renewal 12/02/2020 Compliant - Finalized
SIN-00049186 Renewal 04/02/2013 Compliant - Finalized