Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232348 Renewal 09/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65During the inspection conducted 9/29/2023, the full bathroom in the basement had an oscillating fan and no sources for 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. Community Living & Learning's maintenance man put a permanent exhaust fan in the bathroom. 10/18/2023 Implemented
SIN-00141670 Renewal 08/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1, date of admission 11/10/17 had an initial assessment completed on 1/17/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The failure to complete Individual # 1's initial assessment was an oversight on the Program Specialist's part. This individual's assessment was completed although it was late. To prevent an initial assessment from being completed late Community Living & Learning is doing the following things. The Executive Director provided training to management staff on individual assessments. The Program Director makes a yearly calendar for program specialists of when assessments are due for all individuals. Community Living & Learning has a form for all new individuals that is a check list of things to be completed for new individuals. The form includes completing an initial assessment within 60 days of admission. [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 the timeliness of individual assessments as per 6400.181(a) and the aforementioned tracking systems. Documentation of the training shall be kept. Immediately and continuing at least quarterly for 1 year, the Executive Director or designee shall audit the aforementioned tracking systems and individuals' assessments to ensure, the program specialist has completed all individuals' assessments, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/20/18)] 09/19/2018 Implemented
SIN-00093411 Unannounced Monitoring 04/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)Based on Individual #1's ISP last updated 3/1/16, Individual #1 requires 1:1, staffing to individual ratio during the night due to heightened anxiety and Dysphagia diagnosis with dietary restrictions. Based on Individual #2's ISP, last updated 12/31/15 and Individual #3's ISP, last updated 1/12/16, Individual #2 and Individual #3 require 1:3 staffing to Individual ratio during the night. On 2/25/16 to 2/26/15, Direct Service Worker #1 and Direct Service Worker #2 were working the overnight awake shift from 11:00 PM to 9:00 AM. From 1:00 AM until to 3:30 AM on 2/26/16, Direct Service Worker #2 was asleep on the couch in the living room on the first floor of the home. The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). Direct Service Worker #2 was terminated as a result of sleeping on the job and failing to provide the necessary supervision to the individuals in her care. Community Living & Learning, Inc. created a new Awake-Night Policy and Mandatory Reporter Form as a result of this violation. All staff in the agency were trained and required to sign the new Awake-night policy and mandatory reporter policy. All of the staff at the 21 Coates Home where Individuals 1,2 and 3 live were trained on the Community Living and Learning's Grievance Policy, Incident Management, and the individual's ISPs All awake-nights are required to complete hourly bed checks and indicate the checks in Quickmar which records the exact time of the bed check Community Living and Learning, Inc. will do surprise inspections periodically between the hours of 1:00am and 6:00am to make sure that awake-night staff are not sleeping [Within 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current ISP to ensure staffing ratios are being implemented as written and discrepancy reported to the SC and plan team members as required. Documentation of "surprise inspections" shall be documented and reviewed by the CEO at least quarterly. (AS 8/16/16)] 06/13/2016 Implemented
SIN-00066930 Renewal 08/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom located in the basement does not have an operable window or mechanical 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. The Fan will be attached to the wall so it cannot be removed from the bathroom. Monthly staff will check that the fan remains in place through the monthly Hazard survey done at each home. The survey is checked by the supervisor who will also visually check to see the fan remains in the bathroom.[All bathrooms in the agency homes will be checked for an operable window or mechanical ventilation.(AS 9-16-14)] 08/21/2014 Implemented
6400.71The telephone located in the kitchen did not have the telephone number of the nearest hospital on or near the phone.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. The telephone number list has been revised to include all of the required numbers. The list will be kept by the telephones and staff will check to see the list remains in place during the monthly hazard survey, The supervisor will check the surveys monthly and also check during visits to the home to make sure the list is maintained. 08/21/2014 Implemented
SIN-00179975 Renewal 12/02/2020 Compliant - Finalized
SIN-00082973 Renewal 08/19/2015 Compliant - Finalized