Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238316 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and avoid accidents. There was not a light outside the basement level door to the backyard. There is a light located on the roofline of the three-story home, but there was no switch or control to turn it on from the basement if staff or individuals need to utilize the basement door exit.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A new light was installed on 3/13/24. Attachment # 4, 5 03/22/2024 Implemented
6400.111(e)Fire extinguishers shall be accessible to staff persons and individuals. The fire extinguisher located on the upper level of the home is mounted to the wall in Individual #1's bedroom. The individual has a key lock on their bedroom door and if the door would locked, the other individuals would not be able to access the fire extinguisher in the event of a fire. The fire extinguisher must be located in a common area that is accessible to staff and individuals. A fire extinguisher shall be accessible to staff persons and individuals. The fire extinguisher located on the 2nd floor was moved to the hallway closet located at the top of the steps on 3/14/24. A fire extinguisher label was placed on the outside of the closet door alerting staff of the location. Attachment #6, 7 03/22/2024 Implemented
SIN-00183489 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.51(b)(1)Training records submitted for Staff # 3, hire date 9/2/20, did not include documentation that training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was provided. Training as outlined is required to satisfy regulation.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff person #3 will receive the recommended trainings by 5/14/2021. 06/15/2021 Implemented
SIN-00108273 Renewal 02/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspection was late. It was completed on 08/06/15, then not again until 08/26/16.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 not created until 03/11/16 and the ISP meeting was 03/22/16, so the assessment was not sent to team members 30 days prior to the ISP 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 SC and plan team members at least 30 days before the ISP meeting. See Attached 1. Training will be conducted with all Program Specialists regarding the completion and distribution of 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
6400.213(1)(i)Individual #1's file did not contain a current dated photo.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.Individual #1¿s photo is updated to include a current date. See Attached 3. All individual¿s records will be updated to include identifying marks and a current, dated photograph by 4/28/2017. House Audit Checklist by Coordinator/Specialist is updated to include at least monthly audit of individual¿s record to include identifying marks and a current, dated photograph. See Attached 4. Training regarding Individual¿s records will be conducted with Program Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
SIN-00147622 Renewal 01/15/2019 Compliant - Finalized
SIN-00056107 Renewal 10/02/2013 Compliant - Finalized