Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263894 Renewal 04/21/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16According to the current ISP which was last updated 4/17/25 Individual #1 is 59 years old and diagnosed with severe intellectual disability, autism anxiety, bipolar disorder, obsessive compulsive disorder, cough variant asthma, pneumonitis due to inhalation of other solids and liquids, allergic rhinitis due to pollen, thrombocytopenia, dysphagia, Gerd, hypothyroidism, hypercholesterolemia, scoliosis, and anemia. At the time of the inspection on 4/22/25, a furnace work report dated 1/16/25 from a local heating and plumbing company indicated that the inside of the heating unit and visible duct work is covered in mold. This same report also contains a note dated 2/28/25 that states talked to Mary (last name unknown) and told them that the duct work needs to be removed, and new duct work installed because it cannot be cleaned inside the duct work. It is unclear if Mary was a staff of the provider agency or from the rental management company. Individual #1 was hospitalized from 2/13/25 -- 2/24/25 with a diagnosis of aspiration pneumonia and sepsis. The provider reported they did not receive the furnace documentation regarding the black mold until 3/11/25. As of 4/22/25, the duct work had not been replaced and individual #1 remained living in the home despite the known mold issue and their respiratory issues. Individual #1 was again seen at the emergency room on 4/22/25 and was diagnosed with pneumonia of left lower lobe due to an infectious organism. Due to individual #1's known history of respiratory illnesses (pneumonia, asthma, allergies) failure to address the mold and air quality of the home put the individual at risk of harm. The lack of action taken once the mold issue was identified led individual #1 to remain in an unsafe environment and cannot be ruled out as a contributing factor to the individual's recent hospitalizations.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.Individual #1 was relocated to another home. Incident was filed IM#9608376. The Residential Program will be restructured. There is no longer a Residential Director. The Program will be hiring a Residential Manager and another Residential Program Specialist. In the interim, the Director of Quality Assurance is working closely with the Residential Program Specialist and the Residential Coordinators to ensure consistency and compliance with the program until changes are made. An air quality test was performed on 4/24/2025, see Attachment #45. The CEO has contacted the property owner via email on 5/6/2025 to address the issues, see Attachment #46. If the property owner does not complete the work, then the agency will not use this location and request to have it removed from the license. If the work is completed, an invoice will be sent as Attachment #47. Then another air quality check will be completed and sent as Attachment #48. The CEO will be trained on Regulation 6400.16 no later than 5/31/2025 by the Director of Quality Assurance and will be sent as Attachment #49. 05/31/2025 Implemented
6400.64(a)On the 1/16/25 furnace maintenance checklist form, the heating and plumbing contractor noted that the visible duct work was covered in mold. There is also a note on the form dated 2/28/25 that the company spoke to someone and told them the duct work needs to be removed and new duct work installed as the inside of the duct work cannot be cleaned. The provider does acknowledge they received this furnace form on 3/11/25. At the time of the walkthrough on 4/22/25, the moldy duct work was still in the home and had not been replaced.Clean and sanitary conditions shall be maintained in the home. Individual #1 was relocated to another home. Incident was filed IM#9608376. The Residential Program will be restructured. There is no longer a Residential Director. The Program will be hiring a Residential Manager and another Residential Program Specialist. In the interim, the Director of Quality Assurance is working closely with the Residential Program Specialist and the Residential Coordinators to ensure consistency and compliance with the program until changes are made. An air quality test was performed on 4/24/2025, see Attachment #45. The CEO has contacted the property owner via email on 5/6/2025 to address the issues at 20 S Chestnut St, see Attachment #46. If the property owner does not complete the work then the agency will not use this location and request to have it removed from the license. If the work is completed, a invoice will be sent as Attachment #47. Then another air quality check will be completed and sent as Attachment #48. The CEO will be trained on Regulation 6400.64(a) no later than 5/31/2025 by the Director of Quality Assurance and will be sent as Attachment #50. 05/31/2025 Implemented
6400.73(a)(Repeat from 4/29/24 renewal inspection) At the time of the inspection on 4/22/25 there was no handrail on the four steps leading from the side exit (located inside the office) to the outside. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The CEO has contacted the property owner via email on 5/6/2025 and requested for a handrail to be installed on the side exit, as attachment #46. Once the handrail is installed, a picture will be sent as Attachment #47. Residential Program Specialist and Residential Coordinator will be trained on Regulation 6400.73(a) no later than 5/31/2025 by Director of Quality Assurance, see Attachment #48. 05/31/2025 Implemented
SIN-00242816 Renewal 04/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the 04/30/24, the basement stairs were loose from the supports and had broken treads. The clothes dryer in the basement had a golf ball size amount of lint. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint was removed from the dryer lint trap at the time of inspection. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.67(b) by Director of Quality Assurance, see Attachment #108. The CEO has contacted the property owner via email on 5/6/2024 and requested for the basement to be made inaccessible both from the inside of the home and outside as attachment # 109. If property owner will not padlock the basement to make it inaccessible, then it will be requested for the basement stairs to be repaired. A maintenance request form will be completed for the basement steps and submitted to the CEO and sent as attachment # 110. If the Landlord does not complete the work by 6/30/2024 then the agency will not use this location and request to have it removed from the license. If the work is completed, a picture will be taken of the work and sent in as attachment # 111. 06/30/2024 Implemented
6400.72(b)At the time of the 04/30/24 inspection, the paint on the windows was chipping and peeling. Screens, windows and doors shall be in good repair. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.72(b) by Director of Quality Assurance, see Attachment #112. The Director of Quality Assurance developed a maintenance request form on 5/1/2024 to be used for reporting and tracking progress for all maintenance needs of the home. The new maintenance request form was completed for maintenance needs and submitted to the CEO on 5/3/2024 as attachment # 113. The CEO has contacted the property owner via email on 5/6/2024 to address the maintenance needs of 20 S Chestnut St as attachment # 109. If the property owner does not complete the work by 6/30/2024 then the agency will not use this location and request to have it removed from the license. If the work is completed, a picture will be taken of the work and sent in as attachment # 114. 06/30/2024 Implemented
6400.73(a)At the time of the 04/30/24 inspection, there was no handrail in the inside of the basement exit, nor the exterior steps leading to the backyard from the Bilco door. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.73(a) by Director of Quality Assurance, see Attachment #115. The CEO has contacted the property owner via email on 5/6/2024 and requested for the basement to be made inaccessible both from the inside of the home and outside as attachment # 109. If property owner will not padlock the basement to make it inaccessible then it will be requested for handrails to be placed inside of the basement exit and the exterior of the steps leading to the backyard from the Bilco door. A maintenance request form will be completed for the basement steps and submitted to the CEO and sent as attachment # 116. If the Landlord does not complete the work by 6/30/2024 then the agency will not use this location and request to have it removed from the license. If the work is completed, a picture will be taken of the work and sent in as attachment # 117. 06/30/2024 Implemented
6400.80(b)At the time of the 04/30/24 inspection, the plants next to the home were overgrown and covering the kitchen windows. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.80(b) by Director of Quality Assurance, see Attachment #118. The Director of Quality Assurance developed a maintenance request form on 5/1/2024 to be used for reporting and tracking progress for all maintenance needs of the home. The new maintenance request form was completed for maintenance needs and submitted to the CEO on 5/3/2024 as attachment # 119. The CEO has contacted the property owner via email on 5/6/2024 to address the maintenance needs of 20 S Chestnut St as attachment # 109. If the property owner does not complete the work by 6/30/2024 then the agency will not use this location and request to have it removed from the license. If the work is completed, a picture will be taken of the work and sent in as attachment # 120. 06/30/2024 Implemented
6400.82(e)At the time of the 04/30/24 inspection, the shower did not have a nonskid surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Director of Quality Assurance will purchase a mat for in the shower no later than 5/25/2024. A picture of the mat in the bathtub will be sent as Attachment # 121. The Residential Director and Residential Program Specialist were trained on 5/15/2024 5/17/2024 on Regulation 640082(e) by Director of Quality Assurance, see Attachment #122. 05/25/2024 Implemented
6400.82(f)At the time of the 04/30/24 inspection, the bathroom did not include toilet paper, soap, a trash can and a method for drying hands, or a shower curtain.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. Director of Quality Assurance will purchase soap, toilet paper, shower curtain, trashcan, paper towels and towels for the bathroom no later than 5/25/2024. A picture of the bathroom with all required supplies will be sent as Attachment # 123. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 640082(e) by Director of Quality Assurance, see Attachment #124. 05/25/2024 Implemented
6400.110(a)At the time of the 04/30/24 inspection, there was no smoke detector in the basement. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.110(a) by Director of Quality Assurance, see Attachment #125. The CEO has contacted the property owner via email on 5/6/2024 and requested for the basement to be made inaccessible both from the inside of the home and outside as attachment # 109. If property owner will not padlock the basement to make it inaccessible then a smoke detector will be placed in the basement and a picture will be taken and sent in as attachment # 126. 05/17/2024 Implemented
6400.111(a)At the time of the 04/30/24 inspection, there was no fire extinguisher in the basement.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Residential Director and Residential Program Specialist were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.111(a) by Director of Quality Assurance, see Attachment #127. The CEO has contacted the landlord via email on 5/6/2024 and requested for the basement to be made inaccessible both from the inside of the home and outside as attachment # 109. If landlord will not padlock the basement to make it inaccessible then a fire extinguisher will be purchased and placed in the basement and a picture will be taken and sent in as attachment # 128. 05/17/2024 Implemented
6400.111(f)At the time of the inspection, there was no documentation verifying the fire extinguishers have been inspected in the past year or are newly purchased. 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 # 129. 05/20/2024 Implemented