Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259082 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34There is a door on the first floor next to the stairs that was locked and unable to be opened.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The lock on the door was removed, attachment. 02/12/2025 Implemented
6400.144Individual #21 is prescribed Clindamycin MIS 1% pads. This medication was not present in the home.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The pharmacy was called, by the nurse charge and the medication was prioritized for same day delivery. 01/16/2025 Implemented
SIN-00219065 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)Individual1's Bedroom Door does not close completely and the locking mechanism is broken Screens, windows and doors shall be in good repair. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.32(r)Individuals living at the location do not have doors that have the ability to be locked with the exception of individual 2's bedroom door. Individual 2's door was equipped with an adaptive lock, the remaining individuals did not have doors with a locking mechanism.An individual has the right to lock the individual's bedroom door.Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
SIN-00135810 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The knob on Individual #1's bedroom closet door was missing. The kitchen sink was leaking water. There was a broken window in the vacant bedroom on the second floor. There were 3 spokes missing/broken from the hand rail on the staircase.Floors, walls, ceilings and other surfaces shall be in good repair. The knobs on Individual #1's bedroom closet have been replaced (attached picture #3). The Residential Manager will confirm these knobs stay on the closet during the monthly environment walks. If knobs are noticed to be missing they will be replaced. The Maintenance Department has repaired the leak in the kitchen sink (attached picture #4). The Residential Manager will confirm this isn't an issue by completing environmental walks monthly. Any issues that is found will be addressed with the specific department. Window was being replaced on the day of the inspection (attached picture #5). To eliminate this from happening again the Residential Manager will conduct environmental walks on a monthly bases. Any issues discovered during this walk will be addressed with the proper department. The 3 missing/broken spokes on the hand railing have been replaced (attached picture #6). The Residential Manager will confirm no outstanding issues during his monthly environmental walks. If any issues is addressed the specific department will be addressed. 03/01/2018 Implemented
6400.81(k)(6)There was no mirror in Individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror has been placed in Individual #2's bedroom (attached picture #2). The Residential Manager will confirm the mirror stay in this individuals bedroom during his monthly environmental walks. If found not in room a new one will be order and replaced. 03/01/2018 Implemented
6400.213(1)(i)The Photograph in Individual #2's record was taken on 2/25/13.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Picture was updated on 6/11/18 (attached picture #1). Going forward to stay compliant pictures will be taken every four years. Records Services will make sure this gets accomplished. 06/11/2018 Implemented
SIN-00091131 Renewal 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(5)Individual # 1's assessment dated 1/16/15, did not document his ability to self-administer medication.The assessment must include the following information:  The individual's ability to self-administer medications.A client assessment revision was completed on 12/22/15. See attachment. In the future, the client assessment and ISP for all internal transfers from one program at Woods into the Mollie Woods program will be reviewed by the receiving program specialist and the respective checklist will be completed and submitted to the Program Planning Coordinator. This was discussed during the 11/17/15 Program Specialist meeting. See attached minutes. 11/17/2015 Implemented
SIN-00199985 Renewal 01/31/2022 Compliant - Finalized
SIN-00156320 Renewal 04/29/2019 Compliant - Finalized
SIN-00063881 Renewal 07/28/2014 Compliant - Finalized