Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280512 Renewal 02/02/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 is prescribed Novolog 10 units a day to be administered before breakfast, lunch, and dinner. They were to be administered additional units of Novolog based on their sliding scale. From September 2025 to midway through December 2025, Individual #1 did not receive the correct dosage of Novolog. They consistently received less Novolog than they were prescribed.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Medication Error IM report #9780815 and IM report of Neglect #9780780 were filed on 2/04/2026. The Health Promotion was updated to reference the current prescribed sliding scale order by the newly assigned Residential Program Specialist and staff of the home were trained on updates on 2/04/2026 to ensure all staff were administering the correct dose of Novolog, see Attachments #4 & #5 Individual #1 had an Endocrinology appointment on 2/6/2026, at this appointment the newly assigned Residential Program Specialist requested clarification on questions that were discussed during the licensing inspection. A copy of the appointment notes were obtained, see Attachment #6. Based on clarifications the Health Promotions were updated and staff were all trained, see Attachment #7. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.16 by the Director of Quality Assurance on 2/18/2026, see Attachment #8. 02/18/2026 Implemented
6400.141(c)(6)Individual #1 had a TB test on 7/24/24. No results were documented.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 was scheduled for a TB screening on 2/12/2026, results of TB screening will be sent as Attachment #9. The results of the TB screening will be sent as Attachment #10 once completed. The violation was reviewed with the newly assigned Residential Program Specialist and Residential Coordinator were trained on Regulation 6400.141(c)(6) by Director of Quality Assurance on 2/18/2026, see Attachment #11. The newly assigned Residential Program Specialist and Residential Coordinator were trained on ODP Announcement 24-094 by Director of Quality Assurance by Director of Quality Assurance on 2/18/2026, see Attachment #12. 02/18/2026 Implemented
6400.141(c)(13)The allergies documented on Individual #1's most recent physical completed 9/18/25 do not match Individual #1's ISP. The physical documents that Individual #1 is allergic to Clindamycin. This allergy is not documented in the ISP.The physical examination shall include: Allergies or contraindicated medications.Residential Program Specialist sent an email to the Supports Coordinator on 2/13/2026 requesting to update the ISP with all allergies, see Attachment #14. The ISP was updated by the Supports Coordinator, see Attachment #15. The violation was reviewed with the newly assigned Residential Program Specialist and Residential Coordinator and they were trained on Regulation 6400.141(c)(13) by Director of Quality Assurance on 2/18/2026, see Attachment #16. 02/18/2026 Implemented
6400.144Individual #1 is prescribed Artificial Tears as a PRN. At the time of the inspection, this medication was not available at the home.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1's PRN for artificial tears was listed on the MAR from their other provider when they transitioned to CCCC. The Residential Coordinator verified with the PCP that eye drops were not prescribed on 2/5/2026 and the order was faxed to CCCC on 2/10/2026, see Attachment #18. The QC Artificial Tears Drops were Discontinued on the MAR on 2/10/2026, see Attachment #19. Information was provided to the pharmacy. The violation was reviewed with the newly assigned Residential Program Specialist and Residential Coordinator, and they were trained on Regulation 6400.144 by Director of Quality Assurance on 2/18/2026, see Attachment #20. 02/18/2026 Implemented
6400.166(a)(2)Individual #1's MARs from September 2025 to the present do not include the prescriber for each medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Prescribers were added to all medications on the February 2026 MARs, see Attachment #21. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.166(a)(2) by Director of Quality Assurance on 2/18/2026, see Attachment #22. All staff in the home will be trained on how to document prescribers on the MARs by a Medication Administration Trainer no later than 3/31/2026, and will be sent as Attachment #23. 03/31/2026 Implemented
6400.167(a)(1)Individual #1 did not receive their 2mg of Perphenazine on 12/19/25 at 8pm.Medication errors include the following: Failure to administer a medication.Medication Error IM report #9781193 was file on 2/05/2026. A debriefing was completed on 2/5/2026 with the target following the agency Policy and Procedures for Medication Administration, see Attachment #24. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.167(a)(1) by Director of Quality Assurance on 2/18/2026, see Attachment #25. 02/24/2026 Implemented
SIN-00242805 Renewal 04/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104(Repeat from 5/1/23 Inspection) The fire department notification letter dated 9/21/23 does not include the exact location of the individual bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Residential Program Specialist and Residential Coordinator were trained on regulation 6400.104 on 5/15/24 and 5/17/2024 by the Director of Quality Assurance, see Attachment # 17. Director of Quality Assurance developed a layout for each home showing the exact location of areas of the home including the individual(s) bedroom along with a photo of the home itself. The floor plan was developed on 5/8/2024 along with the picture of the home. Program Specialist updated the fire department letters on 5/6/2024. The fire department letter, floor plan and picture of the home was sent to the fire department on 5/8/2024, see Attachment # 18. 05/17/2024 Implemented
SIN-00223243 Renewal 05/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Self-Assessment was completed on 2/20/23. The time frame for the self-assessment to be completed was from 11/1/22 to 2/3/23.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.Due to lack of knowledge of the regulation, assessors did not take into account both month and day when completing self-assessments. They were trained on 6400.15(a) on 5/17/2023. Attachment #1. 05/24/2023 Implemented
6400.103(Repeat from 5/3/22) The written evacuation procedure developed did not identify the means of transportation or emergency shelter that would be used in the event of an emergency evacuation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Program Specialist misunderstood the regulation. New Evacuation procedures were written to include all required information. Individuals and staff of the home were trained on the evacuation procedures as of 5/17/2023. Attachment #31. 05/17/2023 Implemented
6400.104The letter sent to the fire department on 10/1/22 did not clearly identify the location of the individual's bedroom.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Program Specialist error. The letter for this home was updated to include all correct information and sent to the local fire department on 5/3/2023. Attachment #32. 05/17/2023 Implemented