Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227966 Unannounced Monitoring 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103Emergency Evacuation plan does not include Individual's responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The evacuation plan was revised and updated on 7.21.2023 to include the individuals responsibilities during an emergency evacuation. All staff will be retrained on the plan by 08/31/2023. (Attachment # 1) 08/31/2023 Implemented
SIN-00174770 Renewal 08/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no self-assessment completed for the home at the time of inspection.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. The self-assessment was completed and corrected on 8/18/2020 at the time of the licensing. On 8/31/2020, the Residential Director reviewed this regulation with the Managers and Supervisor. During the quarterly audits the Residential Director will ensure all the programs listed on the certificate of compliance are audited even when the home does not have an occupant. As per regulation, the Residential Director will ensure the home completes a self- assessment within 3-6 months of the certificate of compliance expiration date. The Senior Director of Operations will review the completed self-assessment 3 months prior to expiration of certificate to ensure compliance. 08/18/2020 Implemented
SIN-00156529 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The 6/21/19 annual physical for Individual #1's section, information pertinent to diagnosis in case of an emergency was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1¿s Annual Physical examination form was updated to include information pertinent to diagnosis in case of an emergency (attachment #15a, b, c, d). The Senior Director of Operations will review this regulation with the Residential management team by August 31, 2019 along with this POC. Beginning immediately all completed physical examination will be reviewed by the agency nurse to ensure that the form is completed in its entirety prior to filing in the individuals main log. Compliance with this regulation will be monitored quarterly by audit teams made up of external team members. 08/31/2019 Implemented
SIN-00120010 Unannounced Monitoring 08/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.13From November 12th, 2016 until the unannounced visit on August 18th, 2017 the home was over capacity by one. The maximum capacity specified on the certificate of compliance may not be exceeded.The CEO contacted the family and closed the program on 8/24/2017. The CEO will review and train the Residential management team on the importance of adhering to the licensed capacity as specified on the certification of compliance. The CEO and the Senior Operations Director will ensure that all homes do not exceed the maximum licensed capacity.Whenever a new individual is identified to receive residential services the Senior Operation Director will review the licensed capacity with the Residential director prior to any admissions or services start. To ensure compliance the Senior Operations Director will discuss with the Residential Director during the monthly meeting on any prospective intakes prior to admissions. 08/25/2017 Implemented
SIN-00190379 Renewal 08/03/2021 Compliant - Finalized
SIN-00114088 Renewal 06/28/2017 Compliant - Finalized
SIN-00077974 Renewal 02/17/2015 Compliant - Finalized
SIN-00046488 Renewal 02/06/2013 Compliant - Finalized