Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238315 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature was measured at 123.4 degrees Fahrenheit in the bathtub in the bathroom adjoining the shared bedroom. NOTE: Maintenance staff lowered the water temperature immediately after the inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted on 3/6/24 and was set for 112.8 degrees. Attachment # 1. 03/22/2024 Implemented
SIN-00219600 Renewal 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. Located in the shared bedroom bathroom shower/bathtub were several areas of a black like substance resembling mold/mildew. Approximately a ¼ layer of dust was all along the top of the kitchen cabinets that were directly above the stove and microwave area in the kitchen.Clean and sanitary conditions shall be maintained in the home. Maintanace re-caulked the bathtub/shower on 3/10/23 and staff clean the bathtub on a daily basis. Staff cleaned the kitchen cabinets on 2/28/23. Attachment #1, 2, 3 04/03/2023 Implemented
6400.166(a)(8)Individual #5's February 2023 Medication Administration Record (MAR) did not include the route of administration for their prescription medication Prevident 500 Booster Plus.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Prevident 500 Booster Plus was relabeled to include the route of administration on 3/10/23. Attachment # 5 04/03/2023 Implemented
6400.166(a)(13)Individual #5 is prescribed Fexofenadine 180 mg, take 1 tablet by mouth once daily. There were no initials on the Medication Administration Record (MAR) as the medication being administration on 2/23 and 2/24 at 7pm. The medication appeared to have been administered as the daily medication packs were not in the home.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Training will be completed with Program Specialist on how to document a documentation error on an MAR by 3/24/2023. 04/03/2023 Implemented
SIN-00166282 Renewal 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this chapter expires on 12/7/2019. The self-assessment was not dated so it couldn't be determined if it was completed 3-6 months prior to the license expiration.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. Self-Assessment tool will be scheduled to be completed in July or August in 2020 and each successive year, which is within 3-6 months prior to the expiration date of the agency¿s certificate of compliance. This will be monitored by Martha Gonzalez, Director of IDD Residential Services. 12/21/2019 Implemented
6400.68(b)The water temp in Individual #4's bathroom was 127.1 degrees; the water temp in Individual #5 and Individual #6's bathroom was 126.4 degrees. Both bathrooms exceeded the 120 degree requirement. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted immediately to 118.0 degrees. Daily for 3 months until 4/1/2020, staff will monitor and document the water temperatures to assure 120.0 degrees or less. After that, staff will monitor and document the water temperature weekly until 1/1/2021. Thermometer will be made available for all homes, so that any individuals or staff can check. At anytime that staff or an individual determines the temperature is above 120 degrees, maintenance department will be notified. See attached charting to document compliance. See Attachment 2 04/01/2020 Implemented
6400.101The door at the side exit leading to the driveway could not be opened from either side at the time of this inspection.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The door at the side exit was repaired within two hours of report. See Attachment 1 Ongoing health and safety repairs will be completed as soon possible or other accommodations will be made to assure safety. Ultimately, Individuals will be relocated to a hotel in the event of an unsafe or potentially unsafe maintenance problem. 12/05/2019 Implemented
SIN-00108272 Renewal 02/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace inspection was late. It was completed on 08/03/15 and then not again until 08/22/16.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. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company and written documentation of the inspection and cleaning shall be kept. All furnaces have been verified by 3/3/2017 by John Clemmer, Director of Facilities and Maintenance to ensure current cleaning and inspection. John Clemmer, Director of Facilities and Maintenance will track annual Inspections and Cleanings dates for each site on a chart to help insure accuracy. Schedules for future maintenance will occur 15 days prior to due date. Tracking chart has been initiated to verify compliance. See Attached 2. 04/28/2017 Implemented
6400.181(f)Individual #1's assessment was developed on 11/30/16, only 8 days before the 12/08/16 ISP meeting, so it was not able to be provided to the team at least 30 days before the meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). A checklist is developed to assure scheduling compliance with availability of the Assessment to the team at least 30 days before the ISP meeting for the development, annual update and revision of the ISP. See Attached 1. Training will be conducted with all Program Specialists regarding completion and distribution of the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP by Martha Gonzalez, Director of Community Support Services by May 15, 2017. 05/15/2017 Implemented
SIN-00090966 Renewal 01/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1 is not safe to use or avoid poison and PDI Sani-Hands was not locked. The label read " if swallowed get medical help or contact poison control center immediately ".Poisonous materials shall be kept locked or made inaccessible to individuals. The poison that was left out was immediately locked with all other chemicals. An additional lock was placed on the door leading to the room where the chemical was left out to prevent future occurrences. All staff in the house were retrained on regulation 6400.62(a) 02/12/2016 Implemented
6400.68(b)The water tmperature was 125.3 degrees. Individual #1 is not able to safely regulate the water temperature independently. Hot water temperatures in bathtubs and showers may not exceed 120°F. John Clemmer, maintenance manager started to get the correct setting on the water heater and checking weekly to ensure that we do not have any of these occurrences happen again and keep a steady water temperature. Maintenance staff has been testing the water temperature weekly to ensure compliance. On 2/17/16, the water heater was replaced at 304 South Franklin Street by maintenance. Maintenance will continue to test the water temperature weekly instead of monthly again to ensure compliance. Maintenance has completed the spread sheet and began documenting every week and began doing this as of 1/29/2016. It will be in place on an ongoing basis.. 02/17/2016 Implemented