Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242806 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 # 20. 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 # 21. 05/17/2024 Implemented
6400.111(f)The fire extinguishers were inspected on 6/23/22 and not again until 7/5/23. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The Residential Director and Residential Coordinator were trained on Regulation 6400.111(f) on 5/15/2024 by the Director of Quality Assurance as Attachment # 22. 05/15/2024 Implemented
SIN-00223244 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. Additionally, the following regulations were not reviewed for compliance: 76a-86.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 Regulation 6400.15(a) on 5/17/2023. Attachment #1. 05/24/2023 Implemented
6400.70At the time of the inspection, there was no phone available, easily accessible in the common living area in the home. The only phone in the home was in the locked office.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. There was a misunderstanding of what accessibility was for accessing the telephone. The telephone has been moved to the living room of the home. Picture taken to show compliance. Attachment #33. Residential Coordinator was trained on Regulation 6400.70 on 5/17/2023. Attachment #34. 05/24/2023 Implemented
6400.103(Repeat from Inspection completed on 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 #35. 05/17/2023 Implemented