Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280513 Renewal 02/02/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 purchased a $100 Visa Gift Card. There is no log for this gift card documenting transactions. In January 2026, Individual #1 purchased a large bean bag chair that cost more than $50. This was not documented on the property log.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Individual #1 purchased a $200 Visa Card in December 2025 at the Dollar tree on 12/17/2025, see Attachment #26. Also providing copy of December's Ledger showing the purchase, see Attachment #27. The Gift Card was logged in December on the 17th, see Attachment #28. There were no purchases made from the gift card in December 2025. In January, the gift card was not added to a ledger for January 2026. There were 2 receipts showing money spent from the gift card in January 2026, a purchase to Amazon for the Beanbag for $190.79 on 1/08/2026, see Attachment #29 and a purchase at Dunkin Donuts for $5.82 on 1/19/2026, see Attachment #30. There is a February 2026 ledger showing the remainder amount on the gift card of $3.39, see Attachment #31. A Ledger was completed for January 2026 on 2/6/2026 to show the purchases made for January 2026, see Attachment #32. The Beanbag that was purchased with the gift card on 1/08/2026, was added to the inventory sheet on 2/4/2026 during the time of inspection. 02/19/2026 Implemented
6400.167(a)(1)Individual #1 is to receive 1 teaspoon of QC Hydrogen Peroxide in each ear once a week. They were due to receive this medication on 1/1/26. The medication was not administered.Medication errors include the following: Failure to administer a medication.Medication Error IM report #9780642 was file on 2/05/2026. A debriefing was completed on 2/13/2026 with the target following the agency Policy and Procedures for Medication Administration, see Attachment #36. 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 #37. 02/24/2026 Implemented
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