Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282483 Renewal 01/27/2026 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 1/28/2026 at 11:52 AM, the following poisonous substances were observed unlocked and accessible in the cabinet under the kitchen sink: a 43 count container of Cascade complete dishwasher detergent action packs and a 96 count container of Great Value Advanced Dishwasher Pacs, both with first aid instructions stating "if swallowed, give a glassful of water and call a Poison Control Center or doctor immediately." Individual #1's assessment, completed 11/20/2025, indicated that poisonous substances in the home are locked.Poisonous materials shall be kept locked or made inaccessible to individuals. 01/29/2026 at time of inspection Community Homes, Director Region #11 locked poisonous materials; picture was uploaded to Lifesteps network. 01/29/2026 Not Implemented
6400.141(c)(7)Individual #1's most recent gynecological examination was completed on 8/2/2024. Documentation was provided to which indicated that the gynecologist had cancelled previously scheduled appointments in 2025 and 2026; however, this documentation was on agency medical appointment forms and had not been signed by the physician. No documentation from the physician's office was provided to verify that the gynecologist cancelled the appointments.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. 01/29/2026 Individual #1 received a letter from Physicians office stating the Office rescheduled their complete gynecological examination including breast examination and Pap test from 2024 to 05/11/2026. 05/11/2026 Not Implemented
6400.141(c)(13)Individual #1's physical examination, completed 2/10/2025, did not include the individual's allergies. This section of the physical examinations form was left blank.The physical examination shall include: Allergies or contraindicated medications.02/11/2026 obtained Individual #1's updated Medical Examination form to include Allergies. 02/11/2026 Not Implemented
6400.181(f)Individual #1's assessment, completed 11/20/2025, was provided to the plan team on 1/6/2026 for the individual plan meeting that occurred on 1/6/2026. Notification of the individual plan meeting was sent to the plan team on 10/30/2025. Individual #1's assessment was not provided to the plan team at least 30 calendar days prior to the plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.02/23/2026 Up-to-Date Assessment for Individual emailed to Supports Coordinator and plan team. 02/23/2026 Implemented
6400.182(c)Individual #1's assessment, completed by Program Specialist #1 on 11/20/2025, indicated that Individual #1 could not follow directions on poisonous substance product labels, use poisonous materials safely, or store poisonous materials properly; however, Individual #1's support plan, last updated 12/9/2025, stated that "[Individual #1] would not knowingly misuse heat sources or household chemicals." Individual #1's support plan has not been revised based upon the current assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.02/23/2026 Program Specialist #1 emailed Individual's updated Assessment to Supports Coordinator to request ISP update. 02/23/2026 Implemented
SIN-00221158 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)At 11:07AM on 2/23/2023, the hot water temperature measured 126.2°F at the sink in the kitchen of the home. At 11:13AM on 2/23/2023, the hot water temperature measured 125.9°F at the sink in the half bathroom near the front door of the home.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. "In 2016 Lifesteps Buildings and Grounds installed water valve mixers in all homes to regulate water temperature. Community Homes Director submitted Work order, #45979 on 03/27/2023 to replace water valve mixer. Buildings and Grounds will replace water valve mixer on the home's hot water tank by 04/30/2023." 04/30/2023 Implemented
6400.66There was not a source of outside light of the second floor exit from the staff office.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. "02/24/2023, Director submitted, Work order, #45294, for exterior light to be installed at back exit. Chief Administrative Officer submitted email request to property management. 03/29/2023, Landlord installed an outside light source." 03/29/2023 Implemented
6400.106The annual furnace inspection, completed on 11/25/2022, does not indicate if the furnace was cleaned.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. By 03/31/2023, Vice President of Special Projects and Facilities will update documentation to reflect cleaning occurs concurrently with the documented inspection. 03/31/2023 Implemented
SIN-00150404 Renewal 02/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The program specialist did not sign Individual #1's ISP review for review period from 4/8/18 to 7/7/18.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Program Specialist will be retrained on Regulation 6400.186 by March 31, 2019. In addition, upon completion of the ISP review, including signatures, Program Specialist will scan a copy of the review to a centralized location on the network.Supervisor, Program Specialists or designee will audit ISP reviews monthly to ensure Program Specialist and individual have signed and dated the ISP review. Program Specialists were trained on the auditing procedure March 4, 2019. 03/31/2019 Implemented
6400.186(d)The program specialist did not provide the ISP review for the review period from 4/8/18 to 7/7/18 to plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Program Specialist will be retrained on Regulation 6400.186 by March 31, 2019.In addition, upon completion of the ISP review, including signatures, Program Specialist will scan a copy of the review to a centralized location on the network.Supervisor, Program Specialists or designee will audit ISP reviews monthly to ensure Program Specialist provided documentation to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Program Specialists were trained on the auditing procedure March 4, 2019. 03/31/2019 Implemented
SIN-00091383 Renewal 03/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers for the nearest ambulance was not on or by the telephones in the office, the kitchen, and the living room areas. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Corrected on date of inspection. Supervisors will be retrained on Regulation 6400.71 by April 30, 2016. [Immediately and at least quarterly, the directors will complete an on site check of each community homes to ensure the required telephone numbers are on or by each telephone. Documentation of on site checks of required telephone numbers at each telephone with an outside line shall be kept.(AS 4/25/16)] 04/08/2016 Implemented
SIN-00170847 Renewal 02/11/2020 Compliant - Finalized
SIN-00083205 Initial review 09/01/2015 Compliant - Finalized