Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253685 Unannounced Monitoring 10/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.114(a)At the time of the inspection there was cigarette ash on the brick ledge to the left of the front door. The smoking policy for this home states that the designated smoking area is the backyard. In addition, the policy states that staff are to use fireproof receptacles and ashtrays.If an individual or staff person smokes at the home, there shall be written smoking safety procedures. Every program has a copy of the Smoking Policy for their location. They are alike, except for the location where people can smoke and they all state to discard/ashes in the appropriate provided container. On 10/18/24 we sent each program a copy of their Smoking Policy and a Signature Training Sheet. The Training sheet is to be returned no later than 10/28/24. Additionally, we have sent each program a laminated Smoking Policy to post at their program. I will send Walnut Bottom's Smoking Policy and Training Sheet when I receive it. 10/28/2024 Implemented
SIN-00247584 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment began and ended on 6/5/2024. The self-assessment was not completed within the proper timeframe.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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. We did not recognize we have been misreading the regulations regarding the timing of when the self-assessment is to be conducted. To correct that, our self-assessments will occur between 2/23/25 and 5/23/25, as our license date is 8/23/25. 07/19/2024 Implemented
6400.22(d)(1)On 4/11/2024 Individual #1 purchased an electric shaver for $ 49.96. On 5/16/2024 Individual #1 purchased 5 washcloths, 2 bath sheets, and one 3-drawer cart. As of 7/17/2024 these personal property items have not been added to their property record.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Attachment 1A is the individual's updated Inventory form showing that the overlooked items have been added. 10/08/2024 Implemented
6400.67(a)The hinge is loose on the kitchen cabinet underneath the stove.Floors, walls, ceilings and other surfaces shall be in good repair. The screw was tightened by the Program Supervisor when the licensor left the property. Please see Attachment 3A. 09/10/2024 Implemented
6400.67(b)At the time of the inspection there was an outdoor playhouse with an attached slide located in the backyard. Staff stated that Individual #2 utilizes this slide. The top portion of the slide is cracked and poses a potential risk to the Individual. Floors, walls, ceilings and other surfaces shall be free of hazards.Maintenance repaired the slide, applying new screws to secure it and flex seal tape so the screw heads are not a potential hazard. Please see Attachments 4A, 4B. The individual has been looking on line, with staff, for a new slide. As soon as he selects which one he wants, it will be purchased and installed. 09/10/2024 Implemented
6400.141(c)(13)Individual #1's current physical exam dated 11/24/2023 lists the following allergies: hay fever, pollen, grasses, shrimp, aspirin, sulfa drugs, NSAIDs. However, there is doctor documentation from an appointment on 10/19/2023 stating that they are also allergic to Penicillin. The correct allergies were not recorded on the 11/24/2023 physical, which carried over to the ISP and assessment also being incorrect.The physical examination shall include: Allergies or contraindicated medications.The omission of information regarding the penicillin occurred prior to the individual transferring from an unlicensed apartment program to a licensed group home. However, this does not excuse the oversight. The Program Specialist sent a request to update the ISP with the correct information and has added an Addendum to the Assessment and Medical History (Attachment 5). 09/01/2024 Implemented
6400.181(e)(13)(i)Individual #1's current (initial) assessment dated 4/25/2024 does not document their current level in Health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The current Program Specialist added an Addendum to the individual¿s Assessment (Attachment 7) covering this area. 09/15/2024 Implemented
6400.181(e)(13)(ii)Individual #1's current (initial) assessment dated 4/25/2024 does not document their current level in motor skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The current Program Specialist added an Addendum to the individuals Assessment (Attachment 7) covering this area. 09/15/2024 Implemented
6400.217Individual #1's date of admission is 12/1/2023. Their Release of Information was not signed until 12/29/2023.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. When the individual moved from an unlicensed apartment program to licensed group home on 12/2/23, it was an oversight that his rights were not reviewed when he moved in. They were completed on 12/29/23. 10/03/2024 Implemented
6400.34(a)Individual #1's date of admission is 12/1/2023. Their Individual rights were not informed until 12/29/2023.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.When the individual moved from an unlicensed apartment program to licensed group home, it was an oversight that his rights were not reviewed when he moved in. They were reviewed 12/29/23. 10/03/2024 Implemented
6400.183(a)(3)Individual #1's ISP meeting held on 3/5/2024 did not include a direct care staff person.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.Supervisor signed as Supervisor; no DSPs were available to attend. 09/23/2024 Implemented
SIN-00206530 Unannounced Monitoring 06/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Backyard fence is broken, not secure and nails are sticking out. Floors, walls, ceilings and other surfaces shall be free of hazards.The provider will conduct monthly checks by the home supervisor to assure compliance. 06/27/2022 Implemented
SIN-00201213 Unannounced Monitoring 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aide kit did not contain the tape at the time of the inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tape will be placed in the first aide kit. 03/07/2022 Implemented
SIN-00168449 Renewal 07/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The interior stairs leading up to the attic did not have a non-kid surface on them.Interior stairs and outside steps shall have a nonskid surface. Attachment #5 shows that the stairs leading up to the attic have non-skid strips on them; completed 7/20/20. 07/20/2020 Implemented
SIN-00132138 Renewal 04/23/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The egress to garage has key deadbolt from interior. No key is permanently affixed.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Deadbolt removed/cover installed over location. Attachment #2 04/30/2018 Implemented
6400.165On 2/2/18 individual #1's MAR was blank for carbamazepine 200mg 8pm dose.Documentation of medication errors and follow-up action taken shall be kept. Upon being informed of the MAR error, the Incident was entered into EIM. A copy was given to the licensor at that time (it is in Attachment #10). A policy is being created, by the Dir Res Svs, that will address: the House Supervisor will review the MARs at least once weekly ¿ should they find an error, they will address it at that time; at the end of the month, the Supervisors will deliver the MARs to their Program Specialist, who in turn, will review the MARs for that month ¿ should they find an error, it will be addressed at that time. Both the Supervisor and Program Specialist will initial and date the MAR reflecting when they reviewed it. The Program Specialists will be trained on the policy on 5/31/18 and the Supervisors will be trained at their next meeting on 6/7/18. A copy of the policy and training signature sheets will be submitted no later than 6/8/18. CPARC, historically, has not officially tracked medication errors; the Director of Services is in the process of creating a Med Error Tracking spreadsheet that the Residential Services Administrative Secretary will maintain and update, daily, as med errors are faxed into the main office. Her Supervisor, the Residential Admin Mgr will be responsible for ensuring the spreadsheet is kept up to date. The spreadsheet will be implemented no later than 5/22/18. A copy of the spreadsheet (completed) will be submitted no later than 6/15/18, reflecting med errors up till then. This will lead to the creation of a Medication Administration Error Policy; Supervisors to be trained on 6/7/18; Program Supervisors to be trained on 6/14/18. Training signature sheets and the policy will be submitted no later than 6/18/18. The Dir Res Svs is responsible for the creation and training re: the policy. 06/18/2018 Implemented
6400.181(e)(7)Individual #1's assessment dated 2/2/18 does not include her ability to sense and move away from heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. An Addendum was written for the individual's Assessment and the SC was requested to input the correct information into the ISP; which has been done. In order to ensure areas of the Assessment are not overlooked in the future, an Assessment Check List is being prepared by the Director, Residential Services. The Program Specialists will be responsible for the completion of the check list. When an Assessment is completed, the Associate Director will retain the completed check list and use it as a measurement for the Program Specialists' annual performance evaluation (thoroughness and timeliness). The Program Specialists will be trained on the use of the check List on 5/31/18 at their next regularly scheduled meeting, the Check List will go into effect 6/1/18 and a completed Check List will be submitted no later than 7/1/18. 07/01/2018 Implemented
6400.186(c)(2)Individual #1's ISP reviews dated 8/11/17, 11/3/17, and 2/2/18 did not review the dental and seizure protocol. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. The Individual's dental plan has been reviewed; staff trained on it. A seizure protocol was implemented upon speaking with the individual's doctor; staff have been trained on the protocol. The Program Specialist is responsible for these areas. Attachment 9b. To ensure plans are not overlooked in the future, an ISP Review (Quarterly) Check List was implemented on 3/16/18 for all quarterlies. The Program Specialist is responsible for completing a Check List for each Review, and upon completion, the Associate Director retains the Check List, reviewing it to see it is completed. They use this tool as one measurement to review during the Program Specialists' Annual Performance Evaluation (timeliness and thoroughness). A completed Check List for an individual is attached. Attachment 9a. 05/13/2018 Implemented
SIN-00218598 Unannounced Monitoring 01/30/2023 Compliant - Finalized
SIN-00215120 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00107723 Renewal 04/04/2017 Compliant - Finalized
SIN-00070504 Renewal 01/07/2015 Compliant - Finalized