Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00284517 Renewal 03/04/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The home's Fire Department Notification Letter, dated 12/21/20, did not provide the exact bedroom locations of the individuals who require assistance to evacuate.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. New fire department notification letters were prepared and sent on 3/5/26. 03/05/2026 Implemented
6400.112(i)According to the written fire drill record submitted from 3/4/25 to 2/20/26, at least one smoke detector was not set off during the drill conducted on 11/17/25, as the "Problems Identified" section read, "[Staff] wasn't aware of how to conduct drill. Staff needed the direction from the RM [Residential Manager] of what individual [needed] to get out of the house first. [Staff] also forgot to pull the alarm." In addition, at least one smoke detector was not set off during the drill conducted on 2/20/26, as the "Response of the Persons Involved" section explained, "Staff located the fire and yelled several times to other staff," but the "Problems Identified" field read, "[Staff] wasn't loud. We weren't able to hear [staff] in [the] office. [Staff] didn't pull the alarm. [They] only lifted the cover." A fire alarm or smoke detector shall be set off during each fire drill.All Program Specialists will be retrained by the Residential Directors on the process for ensuring the fire alarm is set off during each drill and conducting a new drill if not set off. 03/16/2026 Implemented
SIN-00222358 Renewal 04/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1, date of admission 8/3/22, had an initial assessment completed on 10/29/22. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. On 4/12/23, the Vice President of Residential Services retrained all Program Specialists on regulation 6400.181(a) relating to the timeframes for completing individual assessments. 04/12/2023 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 10/29/22, to the plan team members on 12/15/22, for an annual plan team meeting on 11/30/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.On 4/12/23, the Vice President of Residential Services retrained all Program Specialists on regulation 6400.181(f) relating to the timeframes for providing plan team members with the individual assessment for the annual plan meeting. 04/12/2023 Implemented
SIN-00183224 Renewal 02/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's most recent assessment was completed on 6-3-20; and the previous assessment was completed on 4-1-19. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. All Program Specialists will be retrained on regulation 6400.181(a) by the Quality, Compliance, and Safety manager. At least quarterly for one year the Quality, Compliance and Safety Manager or designated management employee will conduct audits of 10% of individual records to ensure individuals assessments are completed within 1 year to or 60 calendar days after admission to the home. 02/17/2021 Implemented