Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281015 Renewal 01/07/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)On 1/7/2026, the self-assessment, dated 9/18/2025 for the home had multiple areas in the Staffing section that were not measured and recorded for compliance including but not limited to 6400.43c1-50a and 6400.51a6-52c6.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. - On 1/9/26, Residential Director reviewed Code 15(a) with Program Supervisor who completed the self-assessment for the specific home. - After reviewing Code 15(a) with Residential Director, Program Supervisor signed confirming knowledge of Code 15(a) and implementation of Code 15(a) moving forward to avoid further non-compliance regarding blank sections on the self-assessment. 01/09/2026 Implemented
6400.141(c)(10)Individual #1's physical examination, completed 6/17/25 did not address communicable disease. This section was left blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. 01/12/2026 Implemented
6400.141(c)(12)Individual #1's physical examination completed 6/17/25 did not included physical limitations. This section was left blank.The physical examination shall include: Physical limitations of the individual. - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. 01/12/2026 Implemented
6400.141(c)(14)Individual #1's physical examination completed 6/17/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. 01/12/2026 Implemented
SIN-00220404 Renewal 02/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(d)Individual #1's assessment was signed and dated by the program specialist on 1/10/2023; however, the assessment was sent to the plan team members on 1/9/2023, prior to the completion of the assessment.The program specialist shall sign and date the assessment. The Program Specialist was retrained on this regulation in it's entirety - proof of the training will be emailed to the licensing supervisor upon submission of this plan of correction. 02/10/2023 Implemented
SIN-00170826 Renewal 02/12/2020 Compliant - Finalized