Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258394 Renewal 01/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(b)I was unable to locate Individual Rights on record for Individual One.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.A rights statement has been reviewed with individual One and signed on 3/6/2025. The record will be maintained on file and at the home with all programming documentation for review upon request. The Rights statement is also included as supporting documentation with this plan of Correction. 03/06/2025 Implemented
6400.46(a)Training record for Staff One did not include fire safety training.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff One was trained in fire safety on 2/21/2025. Training record is included with this plan of correction. 02/21/2025 Implemented
6400.46(d)Record for Staff One did not include first aid/CPR/AED certification.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Employee¿s CPR/FA/AED Certificate of training is included in this plan of correction for review. Employee One did take CPR/FA/AED training on June 21, 2024 and is due for retraining in June 2026. 03/07/2025 Implemented
6400.52(a)(1)Record for Staff One does not meet the annual 24hr requirement.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Employee has been assigned training to bring the total hours of training up to 24 hours. The training Coordinator will monitor the progress to ensure Employee One completes all training assigned by the Providers correction date of 3/15/2025. 03/15/2025 Implemented
6400.52(c)(1)Completed trainings for Staff One's record do not meet curriculum requirements as laid forth by regulation subpoints 1-6.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Employee One will be assigned the missing training and complete that training by 3/15/2025. 03/15/2025 Implemented
6400.167(a)(1)Failure to administer medication. medication error for 12/20, 12/23, 12/29, medications omitted due to community outing. No evidence of administration for medications missed. Insulin, Wellbutrin, Metformin, and medication for hyperlipidemia VascepaMedication errors include the following: Failure to administer a medication.The employees who made the documentation errors were retrained in the ODP Medication Administration certification course. The medications in question were taken with the individual and administered on time however the MAR was signed late with no indication that the medication was taken with the individual and administered off site. Staff received retraining in the full medication administration course which includes the correct documentation of medications administered while in the community or on therapeutic leave. Staff responsible for the errors were retrained on 1/31/25, 2/7/25 and 2/17/25 ¿ training documentation accompanies this plan of correction. 02/17/2025 Implemented
6400.181(f)Need letter to the team for Individual One's annual assessments. The shared drive only listed an email that was developed on 1/9/25 announcing attachments ILA LTM, and SEEPS for the Individual One. The letter to the Team regarding the Annual Assessment is what is needed and need to show a send date of 30 days or more prior to the annual.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Provider made attempts to schedule Individual One¿s ISP however there had been no response from the SCO. Program Specialist will contact the SCO to schedule an immediate ISP meeting to be held for Individual 1. Provider will also look to obtain a new SC Individual 1. While waiting for a new SC to be identified, VP of IDD Operations will contact the SCO supervisor to ensure an ISP meeting is held no later than March 31, 2025 03/31/2025 Implemented
6400.183(c)Signature form that is on file is for 01/10/24 which is for the year prior. Individual #1's annual renewal date is 2/5/25 which means that this year's Annual Review meeting took place sometime between 11/5/24 and 12/5/24, but no sign-in sheet was provided for that date range. A second signature form was sent into the shared drive, but it was the exact same expired sign in which was from last year. Need the sign in for THIS year which would have taken place between 11/5/24 and 12/5/24.The list of persons who participated in the individual plan meeting shall be kept.Provider made attempts to schedule Individual One¿s ISP however there had been no response from the SCO. Program Specialist will contact the SCO to schedule an immediate ISP meeting to be held for Individual 1. Provider will also look to obtain a new SC Individual 1. While waiting for a new SC to be identified, VP of IDD Operations will contact the SCO supervisor to ensure an ISP meeting is held no later than March 31, 2025. 03/31/2025 Implemented
SIN-00223835 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual 1 had no fire safety training in the records that showed what curriculum used to train the individual. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The individual had fire safety training on January 6, 2023 and signed off on it. See attachment 32 01/06/2023 Implemented
6400.213(3)The annual physical for individual 1was completed 8/10/2021 and then again on 9/15/2022. The physical was more than 1month late.Each individual's record must include the following information: Physical examinations. The Program Specialist has a tracking spreadsheet to ensure that the individual is on time with annual physical. See attachment 33. 06/07/2023 Implemented
SIN-00207340 Renewal 04/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)10 of the 11 self-assessments completed were not completed 3-6 months prior to the license expiration date or 3-6 months after the last inspection 4/21The 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. Provider created a self inspection spreadsheet with due dates in the folder with the spreadsheet includes completed self inspection forms with the right form to use. 07/15/2022 Implemented
6400.81(k)(6)There was no mirror located in Individual #1 bedroom.In bedrooms, each individual shall have the following: A mirror. Mirror was purchased and installed in the individual's bedroom. 05/17/2022 Implemented
6400.113(a)Individual#1 was admitted into the individual's current residence on 09/02/2021. There is no evidence within Individual #1's Individual Record to corroborate that a Fire Safety Training was provided for the individual on or prior to this date. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Provider informed team an update with changes that anytime an individual who moves in as new admission and/or if currently lives in a CLA licensed home and moving into a different CLA licensed home within the agency, the house manager will be required to conduct a fire drill along with providing fire safety training of the new location. 07/21/2022 Implemented
6400.141(a)The most recent Annual Physicals located within Individual #1's Individual Record occurred on 11/03/2020 and 11/24/2021. Individual #1 did not receive a Physical Examination annually as required.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Provider developed an annual physical tracking spreadsheet to be maintained by the program specialist and care manager for current individuals and new admission (as applicable). This spreadsheet includes previous date of last annual physicals with reminder of next due date of next annual physical. 07/18/2022 Implemented
6400.181(e)(10)Individual #1's Individual Assessment, dated 09/24/2021, did not contain a complete Lifetime Medical History. The document identified as a Lifetime Medical History by the provider, which accompanied the Individual Assessment, contained only Individual #1's medical history for the previous year.The assessment must include the following information: A lifetime medical history. Provider will compile each year's worth of medical history for licensing inspection to show all the years. 07/21/2022 Implemented
6400.34(a)According to the documentation within Individual #1's Individual Record, information on individual rights and the process to report a rights violation to the individual was reviewed with Individual #1 on 03/10/2021 and 03/28/2022. This review did not occur annually as required.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Provider developed spreadsheet to track the due dates of the to ensure it is completed annually and within the appropriate time frame annually. 07/19/2022 Implemented
6400.165(b)Individual #1's (PRN) Medication MELATONIN 3mg, ACETAMINOPHEN 325mg and SILTUSSIN DM 10mg was not on site at time of inspection.A prescription order shall be kept current.House manager reivewed the individual's current eMAR PRN list and got the medication from the pharmacy that were not in the toolbox and were placed in the toolbox. 05/16/2022 Implemented
6400.181(f)There was no documentation within Individual #1's Individual Record to corroborate that the Individual Assessment dated 09/23/2020, was provided to the members of Individual #1's Individual Plan Team by the Program Specialist at least 30 days prior to Individual #1's Individual Plan Meeting on 08/17/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Once the support coordinator reaches out to the provider to set up the individual's annual ISP meeting, the provider will immediately start to compile the individuals records to send to the team within 7 days. 07/21/2022 Implemented
SIN-00253939 Unannounced Monitoring 10/21/2024 Compliant - Finalized