Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233907 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, the bathroom on the left side of the home had a strong smell of urine.Clean and sanitary conditions shall be maintained in the home. Bathroom was thoroughly cleaned using Odoban and bleach on 11/14/23. Staff and Program Supervisor will be retrained on the cleaning process for the bathrooms on 12/6/2023. See supporting documentation. 12/18/2023 Implemented
6400.77(b)At the time of the inspection, there was not a fully intact first aid kit available in the home with all of the contents. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. First aid kit was put together and is intact. Program Supervisor will check monthly at the time of the fire drill to ensure the first aid kit is intact. PS supervisor has been trained on 12/1/23. See supporting documentation. 12/18/2023 Implemented
6400.104The most recent letter sent to the fire department on 6/18/21 has outdated information. The home consists of three males and one female. Individual #1's evacuation needs, and bedroom location are not included in the letter.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. An updated letter was sent to the fire company on 12/1/2023. The Program manager and Program Supervisor were trained on the requirements of this regulation on 12/1/2023. See supporting documentation. 12/18/2023 Implemented
6400.106A furnace cleaning was completed on 2/3/21 and not again until 12/8/22, outside of the annual timeframe.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. On 12/18/2023 the Program Director re-trained the Program Manager and Program Supervisor on the regulations and the need to schedule furnace inspections according to regulations. 12/18/2023 Implemented
SIN-00182699 Renewal 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed 1/26/21 did not include a written summary of corrections.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. All self-assessments will be updated with the written corrective measures taken for each citation. This will be completed by 5/31/21. Directors, PDs, Managers and Specialists will schedule events and alerts in Google Calendars by 5/31/2021 to indicate the start and completion dates for the annual self-assessments, which will be completed 3-6 months prior to the license date of 5/13. The start date will be 11/13/2021 and the completion date will be 2/12/2022. Each event will be set to repeat annually. Upon completion of self-assessments and prior to the due date of 2/12/2022, PDs will schedule a meeting with the Managers and Specialists to review the self-assessments and plans of correction to ensure the plan of correction is written in the self-assessment. All PDs, Managers and Specialists will be retrained in the requirement to include written plans of correction in the self-assessment by 5/31/21. 05/31/2021 Implemented
6400.106There was no furnace cleaning throughout the entire year of 2020.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. POC: The furnace cleaning company was contacted and the furnace was cleaned on 2/3/21. Upon completion of the furnace inspection and cleaning, the Supervisor will send the written documentation of the cleaning to the Manager. The Manager will review and send to the licensing compliance team. The Safety and Fire Drill tool includes verification that furnaces are inspected and cleaned at least annually by a professional furnace cleaning company. The Safety and Fire Drill tool will be completed by the Supervisor at the time of Monthly Safety Check and Fire Drill. The Manager will review the completed form with the Supervisor during supervision meetings to ensure thorough and accurate completion and verification of the furnace inspection and cleaning. Supervisors and Managers will be retrained in the requirements of this regulation and the procedures and completion of the Safety and Fire Drill tool by 5/31/2021. On a quarterly basis the Manager is responsible to complete the quarterly checklist for all physical site and safety requirements. The Manager¿s quarterly inspections will be completed in July, October, January and April. PDs will review the outcomes of the quarterly tools by the last day of each month, July, October, January and April. 05/31/2021 Implemented
SIN-00118921 Renewal 09/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Higmark soap, indicating to contact poison control, was unlocked in the full bathroom. All individuals in the home are not safe with poison.Poisonous materials shall be kept locked or made inaccessible to individuals.The Residential Supervisor disposed of the soap that indicated to contact poison control and replaced it with a nontoxic soap (Seventh Generation) that does not indicate a need to contact poison control. This was completed on 9/19/17. (See photo of soap bottle, attachment #1, see photo of print out showing the soap does not indicate need to contact poison control, attachment # 2). To prevent future incidents of this a list of soap that is acceptable will be provided to staff by 12/7/17. All Direct Support Professionals, Residential Supervisors, Program Specialist and Assistant Program Directors will be trained in regulation 6400.62 (a) by 12/7/17. 09/19/2017 Implemented
SIN-00064014 Renewal 04/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's self-assessment was not completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The self assessment was completed 3/31/13 and the expiration date is 5/13/14.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. Program Specialists, Assistant Program Directors and Program Directors will be retrained on Reg 6400.15(a). The dates that the Self Assessment are due(November 13-February 13) will be added to the Outlook Calendars by the Program Directors. 08/30/2014 Implemented
SIN-00252541 Renewal 09/30/2024 Compliant - Finalized
SIN-00252633 Renewal 09/30/2024 Compliant - Finalized
SIN-00217394 Renewal 01/06/2023 Compliant - Finalized
SIN-00199518 Renewal 02/07/2022 Compliant - Finalized
SIN-00200113 Renewal 02/07/2022 Compliant - Finalized
SIN-00164822 Renewal 01/27/2020 Compliant - Finalized