Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283344 Renewal 02/10/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)On 2/11/26 at 10:08AM, the rear egress leading from the basement contained a set of stairs that was completely covered in snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. February 11, 2026- The Maintenance Director shoveled and removed snow from the basement stairwell to ensure safe and unobstructed access. 02/23/2026 Implemented
6400.112(c)The written fire drill records for the fire drills held on 1/20/25, 2/28/25, 4/1/25, 5/13/25, 6/16/25, 7/23/25, 9/23/25, 11/5/25, 12/3/25, 1/18/26 did not address problems encountered. The written fire drill records for the fire drill held on 9/23/25 did not include the amount of time to evacuate.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. February 13, 2026 -- The Residential Director updated the Monthly Fire Drill Report form to ensure all required elements are answered directly and not left open-ended. The revised form now includes "Yes" or "No" response fields, with a required explanation of any problems encountered during the drill. 02/23/2026 Implemented
SIN-00259153 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)On 1/15/25, at 10:56 AM, the most recent copies of Individual #1's following records were not kept at the home: assessment; physical examination; vision screening or examination; hearing screening or examination; dental examination; dental hygiene plan; and an applicable psychological evaluation. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. 214(b): The most current copies of record information required in 6400.213 (2)-(14) shall be kept at the residential home. January 16, 2025 ¿ The hard copy of individual #1 records was placed at the home in conjunction with the electronic copy that was located within the residence. The electronic copy can always be accessed by using the agency¿s iPad or desktop computer. The hard copy was placed in the individual's # 1 daily binder. 01/24/2025 Implemented
6400.15(b)The agency used the Self-Inspection and Declaration Tool (modified June 2018) to measure and record compliance at the home on Jan. 3, 2025. This Self-Inspection and Declaration Tool does not contain all the elements on the current Department's licensing inspection instrument released on February 20, 2020(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.15(b): The agency shall use the Department¿s licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulation to measure and record compliance. January 20, 2025- The assessment was completed by the residential director using the latest required tool for community homes serving individuals with intellectual disabilities or autism, ensuring compliance with all elements of the Office of Developmental Programs within 6400 regulations. 01/20/2025 Implemented
6400.32(r)(3)On 1/15/2025, at 10:20 AM, Individual #1's bedroom door was equipped with a key and keypad code combination locking system. During an interview conducted with Direct Support Professional #1, it was revealed that Individual #1 does not know how to utilize the key or enter the combination code to disengage their bedroom door's locking system, and the agency did not provide assistive technology as needed to allow Individual #1 to do so without assistance.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.32 (r) (3): An individual has the right to lock the individual's bedroom door. Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. January 15, 2025 - The guardian of individual #1 requested in writing, a door handle without a lock on the bedroom door. January 16, 2025 - The agency's maintenance supervisor removed the electronic lock on the bedroom door and replace it with a door knob without a lock. The maintenance supervisor will assess the home monthly to ensure it meets all codes of compliance for 6400 regulations. 01/16/2025 Implemented
6400.166(a)(5)On 1/15/25, Individual #1's January 2025 Medication Administration Record differed in medication strength from the medication label of the prescribed pro re nata, Milk of Magnesium Suspension---Give 30 ML (2 tablespoonfuls) by mouth as needed if no bowel movement in 3 days. May repeat dose one time if no results within 12 hours. If no results after 2nd dose, contact PCP---in the following manner: Individual #1's January 2025 Medication Administration Record indicated, "Milk of Magn Sus 400/ 5ML," while the corresponding medication label read, "Milk of Mgn Sus 1200/ 15."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.166 (a) (5): A medication record shall be kept, including the following for each individual for whom a prescription medication is administered. Strength of medication. January 16, 2025 ¿ Med-trained staff #1 updated the current MAR to reflect the correct strength of the PRN medication verbatim. 01/16/2025 Implemented
SIN-00237507 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The home had a furnace inspection completed on 12/6/22 and then again on 12/28/23.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Residential homes will have their annual furnace inspected in the proper time frame to remain in compliance. It will be scheduled accordingly with the maintenance coordinator and residential director. 01/31/2024 Implemented
SIN-00201645 Renewal 03/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1, date-of-birth 7/12/85, had a dental examination on 1/6/20 but had no subsequent examinations.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. We have made the individual a Dental appointment for the 1st available slot which is on - We have also given the individuals guardian/ family a deadline of Friday 3-18-22 to determine where they would like the individual to go for dental extractions needed or will the provider will make the appointment with a local oral surgeon. 03/16/2022 Implemented
SIN-00114309 Renewal 05/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1, date of hire 5/2/16, had a physical examination completed 1/6/15. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff person in question was a contracted employee of the agency who decided to terminate her contract and become a paid employee with the residential program. During the transfer between the programs her physical was in compliance for the one program however was then determined out of compliance for the residential program. Moving forward all employee's or transferring employees from another program in the agency will all complete the new hire orientation process again, which includes getting new clearances, physical and TB test. . The process will be monitored by the HR department and then send to the medical coordinator who will track it bi-annually to remain in compliance with regulations. [Immediately and at least quarterly for 1 year, a designee shall review all staff persons current physical examinations completion dates and tracking system to ensure timely completion of staff persons' physical examinations. Documentation of reviews shall be kept. (AS 6/20/17)] 06/15/2017 Implemented
SIN-00219484 Renewal 02/14/2023 Compliant - Finalized
SIN-00185146 Renewal 03/23/2021 Compliant - Finalized
SIN-00172339 Renewal 03/11/2020 Compliant - Finalized
SIN-00153433 Renewal 04/09/2019 Compliant - Finalized
SIN-00133007 Renewal 04/12/2018 Compliant - Finalized
SIN-00092542 Renewal 04/08/2016 Compliant - Finalized