Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281898 Renewal 01/13/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, the ceiling vent located in the main bathroom had a significant amount of dust on it.Clean and sanitary conditions shall be maintained in the home. House staff cleaned ceiling vent in the bathroom. See attachment #1 01/15/2026 Implemented
6400.106: Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. The furnace was inspected on 6/26/24 and then not again until 7/16/25. This exceeds the requirement.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. The Director of Facilities and Maintenance will schedule furnace annual inspection and cleanings one month prior to the last inspection date. 02/18/2026 Implemented
6400.142(d)Individual #1 had dental appointment on 4/14/25, and their record/document indicated under Impression section of the form rectroic teeth #14, 30, and under the treatment section on the form it noted that will plan for ext #14 and #30 under local anesthesia patient is not candidate for sedation. Individual #1 had a dental appointment on 10/30/25, and their record/document indicated under Impression section of the form referral for extractions of teeth #14, 30. Neither appointment form completed for Individual #1 on 4/14/25 or 10/30/25 indicated/documented that teeth cleanings or checking gums and dentures were performed.The dental examination shall include teeth cleaning or checking gums and dentures. Program Specialist will ensure to put the correct reason for consultation on the provider form and will review the completed medical form that was filled out by the provider after the appointment. If information is missing, the Program Specialist will reach out to the provider for further documentation of the appointment. 02/18/2026 Implemented
6400.24The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. Individual #1's controlled medication Alprazolam has been administered without counts being kept.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Program Specialist added medication count function to EHR. Attachment #2. 02/18/2026 Implemented
6400.32(h)An individual has the right to privacy of person and possessions. At the time of the inspection, there was a baby/audio monitor in Individual #2's bedroom on their nightstand next to the bed with one in the living room on the desk to receive the audio from her bedroom. It was not on at the time of the inspection, but agency staff stated it is used at night. It also states in Individual #1's Individual Support plan that supervision is provided at all times to monitor for seizure activity with 15 minute checks in the night and a monitor in her room to alert staff of a seizure.An individual has the right to privacy of person and possessions.Baby/audio monitor was removed. Program Specialist emailed the Supports Coordinator to remove the use baby/ audio monitor use from individuals ISP. See Attachment #3 02/18/2026 Implemented
6400.181(f)The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. Individual #1's assessment dated 11/6/25 was sent to the team on 11/6/25, and Individual #1's Individual Support Plan (ISP) meeting was 11/26/25.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialist will ensure to use the EHR calendar to ensure assessment to individual is completed at least 30 calendar days prior to an individual plan meeting. 02/18/2026 Implemented
SIN-00259806 Renewal 02/27/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(1)Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a pin. These types of locks do not provide the level of privacy and security of person and possessions expected by this regulation.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Staff changed Individual's #1 door lock on 2/28/2025, and Individual #1 was given a key to her bedroom door the same day. Attachment # 15 02/28/2025 Implemented
SIN-00219607 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 around all the way around the middle of the shower on the caulking were several areas of what appeared to be a black like substance resembling mold/mildew.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. Attachment # 8 04/03/2023 Implemented
6400.143(a)On 2/23/23, Individual #3 had a mammogram appointment and it was noted on the form "Pt could not tolerate any compression. She cried in pain, could not hold still. Pictures not taken." The agency completed a refusal form but noted "No" that training has not been attempted. If an individual refuses routine medical treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Training will be completed with Program Specialists on what is expected when an individual refuses an appointment (training with individual, Desent. Plan after so many attempts, etc.) by 3/24/2023. 04/03/2023 Implemented
6400.52(c)(4)There is no documentation that staff #1 received annual training on recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff #2 completed the annual training on recognizing and reporting incidents on 3/14/23. Attachment # 9 04/03/2023 Implemented
6400.165(g)Individual #3 is prescribed medication to treat symptoms of a psychiatric illness. Individual #3 had a medication review on 2/27/23 and the form used did not document reason for prescribing the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Upon further evaluation of Individual #3 psychiatric documentations, there are diagnosis listed where the medications prescribed are. Attachment # 11. 04/03/2023 Implemented
6400.166(a)(2)Individual #3's February 2023 Medication Administration Record (MAR) did not include Dr. Allen as being the prescriber for their prescription medication Docusate.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Program Specialist changed the prescribing doctor to Dr. Allen on the MAR to match the medication docusate. Attachment # 12 04/03/2023 Implemented
SIN-00183495 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Receipts submitted included the purchase of baby wipes on two separate occasions. 1/16/21 Walmart $13.61 and 11/24/20 Sam's $19.04. Incontinence supplies are included in Room and Board costs and are to be purchased by the provider.Individual funds and property shall be used for the individual's benefit. Individual #2 Individuals¿ funds were reimbursed on 4/9/2021. See attached documentation of reimbursement. 06/15/2021 Implemented
6400.82(e)There was no nonslip surface or mat in the large fully accessible bathroom. A nonslip surface or mat is required to ensure safety. Bathtubs and showers shall have a nonslip surface or mat. Nonslip mat was purchased and placed in the individual¿s bathroom shower on 3/22/2021. Attached is photo of nonslip mat. 04/14/2021 Implemented
6400.112(g)Sleep fire drills conducted on 10/10/20 at 1:00am and 4/18/20 at 12:50am. All fire drills must be held at different times of the day and night. Fire drills shall be held on different days of the week and at different times of the day and night. Program Specialist will ensure that fire drills are completed different days of the week and different times of the day and night. 06/15/2021 Implemented
6400.181(e)(13)(i)Assessment dated 8/5/20 noted that Individual #2 "she is on a "pureed diet and is on a strict organic diet." Individualized Feeding Plan dated 8/10/20 for Individual #2 indicated that consistency of food should be "pureed," posture during meals should be" sitting and must remain upright for 30 minutes after eating, drinking or receiving medication." After additional testing and evaluation, the Individualized Feeding Plan for Individual #2 was updated to reflect her current needs. The Individualized Feeding Plan dated 12/10/20 indicates that Individual #2 was now on a "Chopped ¼" unless otherwise specified" diet with "Thin liquids with controlled straw," posture should be "upright in chair at table 90', must remain upright for 30 minutes after eating, drinking or receiving medications." Other instructions included "small spoon a fork is best, controlled straw alternate solids with liquids, clear mouth between bite." The assessment was not updated as required to reflect the individual's current level.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. Individual #2 Assessment was updated on 4/5/2021. Assessment for Individual #2 is attached. 04/30/2021 Implemented
6400.34(a)Individual #2 was informed of her rights on 12/24/2020. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include, lock bedroom door, and civil and legal rights afforded by law, make choices and accept risks, refuse to participate in activities and services, control their own schedule and activities, choice of roommate, furnish/decorate bedroom and common areas, a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, primary caregiver shall have the key or entry device to lock and unlock the door entry mechanism to lock/unlock the front door, access to food, and make health care decisions.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.The provider will review and update the policies and procedures regarding individuals¿ rights. See updated Individual Rights Policy. 06/15/2021 Implemented
6400.165(a)The March 2021 Medication Administration Record (MAR) for Individual #2 included an entry for SAM-E 400mg. The MAR for SAM-E 400mg was written as "Take 1 tablet by mouth once daily with dinner." The MAR entry was documented as "O" on March 1st-10th. Documentation Code on the MAR indicates that "O" represents "not given (make comment)." Notation on the back of the MAR states that "SAM-E was not given because it was not provided due to the pharmacy not being able to get the supplement." Review of the February 2021 MAR for individual #2 shows that SAM-E was not given during the month with a notation on the back of the MAR "SAM-E out of stock." A review of the January MAR for Individual #2 indicates that the SAM-E was given from 1/1/21-1/11/21. MAR indicates that as of 1/12/21 the medication was not administered as prescribed. Notations on the back of the MAR include "SAM-E was not given because we don't have it." And "SAM-E was not given 1/29-1/31 due to not being at the house." Medications are to be administered as prescribed.A prescription medication shall be prescribed in writing by an authorized prescriber.SAM-E was obtained on 3/12/2021 and administered to Individual #2 at her next schedule dose. Policy was developed to fill unavailable Medications. See attached. 04/30/2021 Implemented
6400.166(a)(11)The March 2021 Medication Administration Record (MAR) for Individual #2 does not include the diagnosis or purpose of the medication for any of the medications entered. Clobazam, Clonazepam, Ofloxacin, Organic Whey Protein, Triamcinolone Cream, Benzonatate, Ceravite, Coenzyme, Folic Acid, Vitamin B-12, Levetiracetam, Digestive Enzymes Caps, Fluticasone Prop, Levocarnitine, SAM-E and Ketaconazole did not contain a diagnosis or purpose for the medication as required.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The provider will request from each individual doctor¿s their diagnosis for each of their medication. The pharmacy will add the diagnosis to MAR¿S. Attached is request for request of diagnosis for physicians. 06/15/2021 Implemented
SIN-00129570 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #3 was admitted on 6/3/2017. He wasn't informed of his Individual Rights until 6/7/2017.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. ¿ CSS Director will develop a checklist including Individuals Rights training and review it with Program Specialists to ensure Licensing requirements and expectations of compliance upon new individual admissions. (Please see attached #5). ¿ Program Specialist will complete/follow a checklist upon individual admission ensuring compliance with all Licensing requirements ¿ The program Specialist will be responsible to ensure the checklist is completed upon individuals admission ¿ The review of the checklist will be completed by 4/15/2018 and ongoing basis as required. 04/15/2018 Implemented
6400.113(a)Individual #3 was admitted on 6/3/2017. He didn't receive initial fire safety training until 6/7/2017. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. ¿ CSS Director will develop a checklist including Fire Safety training and review it with Program Specialists to ensure Licensing requirements and expectations of compliance upon new individual admissions (Please see attached #5). ¿ Program Specialist will complete/follow a checklist upon individual admission ensuring compliance with all Licensing requirements ¿ The program Specialist will be responsible to ensure the checklist is completed upon individuals admission ¿ The review of the checklist will be completed by 4/15/2018 and ongoing basis as required. 04/15/2018 Implemented
6400.181(e)(4)This area was blank on Individual #3's initial assessment dated 6/27/2017. The assessment must include the following information: The individual's need for supervision. Program Specialist completed the Initial Assessment and individuals need for supervision is completed. (Please attached #3) ¿ Program Specialist will continue to complete individual¿s Assessment on a regular basis as required. ¿ The program Specialist will be responsible to ensure individual¿s Assessments completely and up to date ¿ Ongoing basis as required. 03/28/2018 Implemented
6400.181(e)(14)This area was blank on Individual #3's initial assessment dated 6/27/2017.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. ¿ Program Specialist completed the Initial Assessment and individual¿s knowledge of water safety and ability to swim. (please see attached #4) ¿ Program Specialist will continue to complete individual¿s Assessment on a regular basis as required. ¿ The program Specialist will be responsible to ensure individual¿s Assessments completely and up to date ¿ Ongoing basis as required. 03/28/2018 Implemented
6400.186(a)Individual #3 was admitted on 6/3/2017. He didn't have an ISP Review until 1/28/2018, which exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. ¿ Program Specialist completed the 10/14/2017 ISP Review for Individual #3 and obtained signatures on 01/28/2018 and January 2018 ISP Review also completed. (please attached #2). ¿ Program Specialist will continue to complete individual¿s ISP Reviews on a quarterly basis as required. ¿ The program Specialist will be responsible to ensure individual¿s ISP Reviews are completely and up to date ¿ Ongoing basis as required. ((ISP Reviews must be completed and signed within the 90 day period. A 15 day grace period shall be considered compliant. -CH 4/10/18)) 03/28/2018 Implemented
6400.213(1)(i)Religious Affiliation was not listed in Individual #3's record.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 #3 records was updated listing the Religious Affiliation ¿ Program Specialist will continue to complete individual¿s records as required and when changes are needed. (please see attached #1) ¿ The program Specialist will be responsible to ensure individual¿s records are up to date ¿ The individual record was completed on 2/13/2018. 02/13/2018 Implemented
SIN-00060929 Unannounced Monitoring 02/26/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 02/05/2014 Individual #1 was in the bathroom and was yelling for assistance when staff #1 told her to "shut up" . That inappropriate comment constitutes verbal abuse. Individual #1 is wheelchair bound but is able to take care of her hygiene needs independently. Individual #1 did not sustain any type of physical or mental problem as a result of this incident.(a) An individual may not be neglected, abused, mistreated or subjected to corporal punishment. STAFF WILL BE RETRAINED ON INCIDENT MANAGEMENT POLICY OUTLINING ANY TYPE OF ABUSE, SPECIFICALLY WHAT IS CONSIDERED VERBAL ABUSE AND NEGLECT, AND HOW TO USE PROPER LANGUAGE TO MEET THE NEED OF THE INDIVIDUALS WHEN THEY REQUIRE ASSISTANCE. THIS POLICY ALSO INCLUDES REPORTING GUIDELINES AND TIMES FOR ANY INCIDENTS THAT OCCUR. 03/28/2014 Implemented
SIN-00090967 Renewal 01/27/2016 Compliant - Finalized