Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233918 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the inspection on 11/15/23, there was a slightly larger than a golfball size of lint in the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.Lint screen was cleaned on 11/15/2023 and staff were trained by the Program Manager on the regulatory requirement concerning lint removal. Training occurred on 11/28/2023. See supporting documentation. 12/18/2023 Implemented
6400.81(k)(1)At the time of the inspection on 11/15/23, there was no bed in individual #2's bedroom.In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in their recliner. Changes were made to the ISP and staff were trained on the updated ISP on 11/28/2023. See supporting documentation. 12/18/2023 Implemented
6400.81(k)(2)At the time of the inspection on 11/15/23, there was no mattress or foundation in individual #2's bedroom.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in their recliner. Changes were made to the ISP and staff were trained by the Program Manager on the updated ISP on 11/28/2023. See supporting documentation. 12/18/2023 Implemented
6400.81(k)(6)At the time of the inspection on 11/15/23, there was no mirror in individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was purchased and placed in individual #1's bedroom on 11/15/2023. Staff were trained by the Program Manager on the requirement for a mirror in all individuals bedrooms on 11/28/2023. See supporting documentation. 12/18/2023 Implemented
6400.32(d)At the time of the inspection, individual #2 did not have a bed available to them at their residence. Staff indicated individual #2 prefers to sleep in the chair and that this is outlined in the ISP. The individual's ISP does not indicate this as the individual's preference, however.An individual shall be treated with dignity and respect.Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in a recliner. Changes were made to the ISP and staff were trained by the program manager on the updated ISP on 11/28/2023. See supporting documentation. 12/18/2023 Implemented
SIN-00182712 Renewal 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The home inspection completed on 1/15/21 contained 2 different violations that were found during the agency's inspection. There is no summery of corrections that were made to the violations found.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
SIN-00164835 Renewal 01/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's bathroom the sink cabinet the wooden varnish is coming off on the right side, the dry wall is not finished, letting the screw heads exposed and not painted, and there was peeling paint by the side and top of the linen closet door in the bathroom.Floors, walls, ceilings and other surfaces shall be in good repair. Individual #1s bathroom sink cabinet was repaired and painted, drywall was finished and painted, and peeling paint was repaired and painted by the side and top of linen closet door in bathroom on 2/20/20. See pictures of individual #1s bathroom and copy of contractor invoice. For all Physical Site regulations, 61 (a) - 86, if DSPs or Supervisors notice a non-compliance, staff will fix the issue, immediately. If the issue cannot be resolved immediately, DSPs and Supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home notes in the EHR. On a quarterly basis, the Manager is responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. This includes assessing the home¿s ability to meet an individuals mobility and need for adaptive equipment. The tool for all physical site and safety requirements will be reviewed and revised by 6/15/2020 and all Managers will be trained on the use of the tool and the quarterly inspection requirements by 6/30/2020. The Manager 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. Program Directors will complete a walkthrough of each home in CSG to insure agency wide compliance with all physical site and safety requirements utilizing CSs Risk Management tool. The Risk Management tool will be reviewed and revised by 7/31/2020 and PDs will be trained in the tool by 8/15/2020. All walkthroughs will be completed by October 31, 2020. All staff, Supervisors, Managers and Specialists will be retrained in the regulations for Physical Site and this plan of correction by 6/30/2020 . 10/31/2020 Implemented
SIN-00118936 Renewal 09/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bottom drawer on the night stand in an individual's bedroom was broken. The bedroom dresser had two holes in the metal screen door.Floors, walls, ceilings and other surfaces shall be in good repair. The Program Director ordered bedroom furniture including a dresser, and night stand which were replaced on 9/25/17. (See invoice showing a new dresser and night stand were purchased, attachment # 5. See photo of night stand, attachment # 6. See photo of dresser, attachment # 7). To prevent future occurrences, all Residential Supervisors, and Assistant Program Directors will be trained in regulation 6400.67(a) and the responsibility to address/report any surfaces that are not in good repair will be reviewed with them. Training and review of responsibilities will be completed by 12/7/17. 09/25/2017 Implemented
6400.112(c)The 5/31/17 fire drill log did not indicate if the living room detector was operable.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The staff failed to indicate that the living room detector was operable on the 5/31/17 fire drill log. The Assistant Program Director Reviewed the Safety and Fire Checklist and Fire Drill Check list from 10/14/17 showing that all smoke detectors in the home are operable. (See copy of 10/14/17 Safety and Fire Check list, attachment # 3 and 10/14/17 Fire Drill Check list, attachment # 4). To prevent future occurrences, all Direct Support Professionals, Residential Supervisors, Program Specialists and Assistant Program Directors will be retrained in regulation 6400.112(c) and will be retrained on Community Services Group Policy and Procedure for completion of Fire Drills and Monthly Safety System Checklist. This will be completed by 12/7/17. 10/14/2017 Implemented
6400.164(a)Ketoconazole 2% shampoo prescribed on 9/15/17 was not listed on the medication administration log.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. The Direct Support Professional updated the medication log on 9/22/17 to include the Ketoconazole 2% shampoo that was prescribed on 9/15/17. (See copy of the updated medication log attachment #2). To prevent future occurrences, all Direct Support Professionals, Residential Supervisors, Program Specialists and Assistant Program Directors will be trained in regulation 6400.164(a) by 12/7/17. 09/22/2017 Implemented
6400.165On 8/23/17, the 8am dose of Lactulose was administered at 9:55am. A medication error was not entered into EIM.Documentation of medication errors and follow-up action taken shall be kept. The Assistant Program Director entered a medication error into the EIM system on 9/21/17 for the late dose of Lactulose on 8/23/17. This is EIM # 8358369. (See attached EIM report showing documentation of the medication error and follow up action, attachment # 1). To prevent future occurrences, all Direct Support Professionals, Residential Supervisors, Program Specialists and Assistant Program Directors will be trained in regulation 6400.165 by 12/7/17. 09/21/2017 Implemented
SIN-00278352 Renewal 12/01/2025 Compliant - Finalized
SIN-00270026 Unannounced Monitoring 07/14/2025 Compliant - Finalized
SIN-00252552 Renewal 09/30/2024 Compliant - Finalized
SIN-00252644 Renewal 09/30/2024 Compliant - Finalized
SIN-00217407 Renewal 01/06/2023 Compliant - Finalized
SIN-00199532 Renewal 02/07/2022 Compliant - Finalized
SIN-00200126 Renewal 02/07/2022 Compliant - Finalized
SIN-00064019 Renewal 04/21/2014 Compliant - Finalized