Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259175 Renewal 02/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.110(c)Staff #1 has participated in all 3 fire drills conducted within the last year (1/2/24, 7/5/24, and 1/29/25). However, Staff #1 has not completed fire safety training since 10/11/2023.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).Staff #1 was fire safety trained by Program Specialist on 2.6.25. (see attachment C) All other provider files were checked on 2.5.25 by Program Specialist and no other issues were found (see attachment A) . 02/06/2025 Implemented
6500.84Firearms stored in Staff #1's bedroom are in a gun cabinet with the key in the cabinet lock. Gun cabinet is required to be locked.Firearms shall be kept unloaded in a locked cabinet. Ammunition shall be kept in a locked cabinet that is separate from firearms.Staff #1 got a new gun cabinet on 2.8.25 with a combination lock (see attachment E) so cabinet will always be locked and no key is needed to be locked separately. The combination will not be known to the individuals or posted anywhere. All other sites were checked by PS on 2.7.25 and no other issues were found (see attachment F) 02/08/2025 Implemented
SIN-00240380 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The license expiration date is November 10, 2023. The self-assessment was completed one month before the license expiration and not 3-6 months prior to the expiration date, on 10/11/23.If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate 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.Program Director and Executive Director reviewed the self assessment process/regulation and determined the dates that would be used to meet the regulation. Program Director put all information in an email on 3.7.24 (attachment #1) and sent it to all program staff so the schedule could be reviewed. 03/07/2024 Implemented
SIN-00200719 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.110(c)Staff # 1 was trained in Fire Safety on 10/01/20 and not again until 10/25/21 exceeding the annual training requirement.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).Provider was scheduled by the program specialist for next annual training (see attachment J) 02/14/2022 Implemented
6500.152(a)Individual # 1's ISP dated 03/23/21 reads that she has a constipation protocol and a bowel movement tracking for administration of Milk of Magnesia. This information is no longer accurate and was not updated as needed. There is no current protocol or bowel movement tracking for Individual # 1.The life sharing specialists shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team.ISP updates were sent to the SC by the RDS Medical Compliance Specialist on February 17, 2022 and updates were made to the ISP on 2.18.22, please see attachment A (ISP date and email) 02/18/2022 Implemented
SIN-00219659 Renewal 02/21/2023 Compliant - Finalized