Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257273 Renewal 12/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisonous materials were found unlocked beneath Individual Two's bathroom sink (soaps/shampoos). Poisonous materials were also found unlocked in Individual One's bedroom (toothpastes, body washes). The ISP for Individual Three indicates that all poisonous materials in the household must be locked.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisons were locked away into the poison closet. Locks were also purchased for the bathroom cabinets to store poisons. 01/14/2025 Implemented
6400.82(e)There was no bathmat or non-slip surface in Individual Two's shower. Bathtubs and showers shall have a nonslip surface or mat. Nonslip shower mat was ordered on 12/16/24 and delivered to the home and placed in the individual's shower on 12/19/24 01/14/2025 Implemented
6400.111(f)The second floor fire extinguisher was last serviced June 2023 and was considered past-due for inspection. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire extinguisher was replaced with an inspected/approved current fire extinguisher. 01/14/2025 Implemented
6400.181(e)(14)Individual One's assessment does not clarify on the individual's ability to swim. The ISP directly states an inability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Individual was discharged from Bancroft on 1/5/25. Program manager will ensure that all abilities in ISP are stated in assessments for all individuals. 12/13/2024 Implemented
6400.163(d)Prescription medication Clotrimazole-Betamethasone Cream 1%/0.05% was found in individual One's bedroom. This individual does not self-medicate.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Individual was discharged from Bancroft on 1/5/25. Staff will do daily checks to ensure all medication is locked away for all individuals. 01/14/2025 Implemented
6400.163(h)Individual One had discontinued medications on hand. Older dosages and instructions are still being stored alongside the active medications. Ibuprofen 200mg tablets (PRN), Acetaminophen 500mg tablets (PRN) Trazadone 50mg tablets (PRN) have had all been updated to new dosages (650mg, 400mg, 100mg respectively).Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Individual was discharged from Bancroft on 1/5/25. Staff will ensure to complete and thorough medication checks and dispose of expired or discontinued medications. 01/14/2025 Implemented
6400.165(c)For individual One, the instructions on the prescription label for Aripiprozole 15mg tablet do not align with the packaged medicine. Instruction states to take 1 tablet by mouth at bedtime - the blister packs for the medication have each dose packaged as a half-tablet, which would be 7.5mg.A prescription medication shall be administered as prescribed.Individual was discharged from Bancroft on 1/5/25. Staff will ensure to complete and thorough medication checks to ensure that the proper medication is being given and that all medication that do not belong will be removed from the individual's medication drawer. 01/14/2025 Implemented
SIN-00180933 Renewal 12/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)A record of financial resources, including dates and amount of deposits and withdrawals was not provided for individual #2 at time of inspection. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. These records are kept by the finance department. Program has requested a record of the financial resources for individual #2. See attachment #6. Going forward, program will request a yearly, or as requested, financial record from the finance department to keep on file in the program. 01/29/2021 Implemented
SIN-00155721 Renewal 04/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)This home's self-assessment and did not complete pages 4, 5, and 6.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. All Management staff of the appropriate departments have been retrained on the 6400 Self Assessment tool. This was completed on 5/6/2019. Going forward, all new management staff will also be trained on the Self Assessment Tool. 05/06/2019 Implemented
6400.70There was no telephone in the first floor of the home. The only phone was in the staff office on the upper level of the homeA home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Phone was purchased for the home. 30 days after a new home opens a second 6400 self assessment tool will be conducted by the Program Manager to ensure that all regulations are met. 05/06/2019 Implemented
6400.76(a)There were multiple boards filled with protruding nails sticking out located in the garage. Furniture and equipment shall be nonhazardous, clean and sturdy. This was left over from a construction job done at the home. Garage was cleaned out. Boards with protruding nails sticking out were removed from property. 05/06/2019 Implemented
6400.111(a)There was no fire extinguisher in the upper level of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A fire extinguisher has been installed in the upper level of the home. A health and safety checklist of the home and the environment is completed monthly, and approved by the Program Manager. 06/19/2019 Implemented