Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238323 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Surfaces shall be free of hazards. The glass fiber (also known as fiberglass) insulation located on the basement ceiling had tears in the outer covering and clumps of the fibers from the insulation were on the basement floor. The fibers from the insulation may pose a hazard to staff persons or individuals if inhaled. Floors, walls, ceilings and other surfaces shall be free of hazards.insulation was replaced and a vapor barrier was used to prevent fibers from the insulation falling on the floor on 3/19/24. Attachment # 15, 16 03/22/2024 Implemented
6400.181(a)An individual shall have an assessment completed within 60 days of admission and annually thereafter. At the time of the inspection, Individual #1's record contained an annual assessment dated 11/10/2023 and an assessment dated 1/25/2021. When asked to see the individual's 2022 assessment to determine if the current assessment was completed on time, the licensing inspector was given a document that was not signed by a program specialist and did not contain any dates to indicate when it was completed. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Program Specialists will ensure to sign and date the annual assessment when it is completed. The electronic health record systems that is being adopted by Threshold will help ensure paperwork is signed in a timely manner. 03/20/2024 Implemented
SIN-00129461 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Hand soap was not accessible in the bathroom. Staff reported that it is kept locked in another area of the house.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. ¿ Program Specialist was able to placed hand soap in the sink at the time of the inspection on 2/13/2018. (Please see attached #9). ¿ Program Specialist will make sure that the programs have hand soap available. ¿ The Program Specialist will be responsible to ensure there is hand soap available. ¿ Effective on 2/13/2018. The process is effective immediately and will be ongoing as needed. 02/13/2018 Implemented
SIN-00071381 Renewal 11/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A fire drill during sleeping hours was not held every 6 months. An asleep fire drill was held on 2-20 2014. There were no additional sleep fire drills held.A fire drill shall be held during sleeping hours at least every 6 months. A schedule will be created and monitored by the Team Coordinator to ensure that fire drills are conducted monthly with a sleep drill occuring every 6 months. 12/30/2014 Implemented
SIN-00056106 Renewal 10/02/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The kitchen table top was not attached to the table base thereby creating a hazard to the Individuals residing at this home.(a) Furniture and equipment shall be nonhazardous, clean and sturdy. Upon discovery during licensing visit, maintenance staff were dispatched and firmly affixed and secured the table top to the base on the same day. 10/02/2013 Implemented
6400.112(d)The evacuation time for a drill held on June 25, 2013 was three minutes which exceeds the allowable 2 1/2 minute time limit.(d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Staff will be trained in fire drill procedures and documentation on 11/18/2013. Review of regulation 112(d). Staff will complete a fire drill form, and discuss evacuation times. Staff will continue to follow proper procedure and document accurate evacuation time. Accepted ---Partially Implemented----RS 11/18/2013 Implemented