Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260498 Renewal 02/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 2/12/25 at 10:58 two screens were missing from two of the windows in the dining room. At 11:01am there was a missing screen located in the upstairs bedroom, first bedroom on the right, after going up the stairs.Windows, including windows in doors, shall be securely screened when windows or doors are open. The Maintenance Technician located the screens in the basement of the home on 2/14/2025 and fitted them into the windows (Attachment #5, #6, #7). 02/14/2025 Implemented
SIN-00146339 Renewal 12/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(e)The full dates of the medications administration training was not documented for Direct Service Worker #1. The dates of the annual practicum were documented as 3/17 and 6/18. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.The Direct Service Worker #1 will receive retraining in medication management on 12/19/2019 by a medication administration trainer. Documentation of the date, including month, day and year will be clearly identified on the training forms and annual practicums (Attachment #3). Medication Administration trainers will work together to review documentation on a quarterly basis to ensure that documentation is clear and comprehensive for all trainings and annual practicums. The Executive Director or designee will review 25% of medication administration training records on a quarterly basis to ensure on-going compliance. [Within 30 days of receipt of the plan of correction, CEO shall educate all aforementioned staff persons on their aforementioned responsibilities to ensure documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept .Documentation of aforementioned audits shall be kept. (DPOC by AES,HSLS on 1/2/19)] 12/19/2018 Implemented
6400.186(a)The program specialist completed the ISP reviews for Individual #1 from the period of 3/1/18 to 5/31/18 on 6/19/18 and the period of 12/1/17 to 2/28/18 on 3/16/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialists will ensure that ISP reviews occur no later than the 15th of the month following the ISP review period. Program Specialists will meet with the individual on or before this date to ensure compliance. Program Specialists and the individual will sign and date the ISP review form to document compliance with this chapter. The Executive Director or designee will review 25% of client records related to ISP review meetings on a quarterly basis.[Within 30 days of receipt of the plan of correction, CEO shall educate the program specialists on their aforementioned responsibilities to ensure they complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Documentation of aforementioned audits shall be kept. (DPOC by AES,HSLS on 1/2/19)] 12/15/2018 Implemented
SIN-00068570 Renewal 12/16/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The non-slip mat in the bathtub/shower was soiled with a dark substance.Clean and sanitary conditions shall be maintained in the home. A new mat was purchased and placed in the bathtub. Program Specialist will train Direct Care staff on maintaining clean and sanitary conditions in the entire home at all time and they will be advised to notify Program Specialist of any time that a new mat needs to be purchased so that it can be done in a timely manner. 12/23/2014 Implemented
SIN-00201677 Renewal 03/03/2022 Compliant - Finalized
SIN-00166124 Renewal 11/14/2019 Compliant - Finalized
SIN-00105952 Renewal 12/22/2016 Compliant - Finalized
SIN-00060810 Initial review 03/07/2014 Compliant - Finalized