Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285481 Renewal 03/23/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(10)The physical for individual #1 did not include whether or not the individual was free of communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Program Specialist and Nurses will be retrained on Regulation: 6400.141(c)(10). Physical examination for individual #1 was sent to PCP for review and update. 05/18/2026 Implemented
6400.166(a)(11)The MAR for individual #1 did not include the diagnosis for any of the prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The agency is actively working with the pharmacy to correct missing diagnoses in the MAR. The diagnosis and purpose for each medication, including PRN medications, will be added to the eMAR to ensure compliance. Staff will verify that this information is documented before administering medications, and ongoing monitoring will be conducted to maintain compliance. 05/18/2026 Implemented
SIN-00186327 Renewal 04/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(c)Basement egress cannot be locked from outside, as residential staff does not have key, making this outside door lock inoperable. This egress is locked from inside the home by a turning lock and a sliding lock. Outside doors shall have operable locks.On 4/15/2021 the doorknob and lock were replaced to ensure access from the outside. 04/15/2021 Implemented
SIN-00134329 Renewal 04/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill on 9/7/17 did not indicate if the alarm system 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. On 5/10/18 the Associate Director conducted training with Program Specialists and Residential Managers focused on ensuring the mandatory use of the electronic fire drill form, equipped with mandatory fields that ensure compliance to regulatory requirements, which includes whether the alarm systems are operable. The Residential Manager will ensure the completion of the fire drill form using the electronic record system each month and will document on the monthly checklist and submit to the program specialist for review. The Program specialist will review the electronic records system to ensure the utilization of the electronic form and will maintain a tracking chart for that purpose. The Associate Director will complete a quarterly review of the tracking charts with the program specialists and will initial each month checked. 05/10/2018 Implemented
SIN-00052233 Renewal 09/16/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(i) Individual #1's assessment dated 12-19-12 did not address progress and growth in all required areas. (i) Health. (ii) Motor and communication skills. (iii) Activities of residential living. (iv) Personal adjustment. (v) Socialization. (vi) Recreation. (vii) Financial independence. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health. The Manager of Residential Programs has retrained the Program Specialists to ensure that each individuals assessment shows progress and growth in the areas of health, motor and communication skills, residential living, personal adjustment, socialization, recreation and financial independence. The Program Specialist will complete each individuals annual assessment as required and forward the assessment to the Manager of Residential Services for review and approval. The Manager of Residential Services will sign off on the assessment indicating their approval. Training was completed on 10/24/13. 10/24/2013 Implemented
SIN-00158972 Renewal 07/18/2019 Compliant - Finalized
SIN-00067518 Renewal 09/22/2014 Compliant - Finalized