Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285483 Renewal 03/23/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The toaster's internal components and its crumb catchment tray contained excessive crumbs. The crumbs were removed during the inspectionClean and sanitary conditions shall be maintained in the home. Staff immediately cleaned the crumbs during the inspection. Staff will be retrained on the importance of keeping small appliances clean, including bread toasters clean in compliance in maintaining clean and sanitary conditions in the home. 05/18/2026 Implemented
6400.67(a)Repairs were needed to the first-floor bathroom showerhead that was leaking, and the second-floor bathroom shower showed water penetration behind the tiles and mounted soap dish as well as peeling paint.Floors, walls, ceilings and other surfaces shall be in good repair. Work order was submitted to the maintenance department and repairs completed on 03/25/26. The Program Specialist will retrain staff on identifying areas in the home needing maintenance/repairs and reporting the concerns to the Residential Supervisors. The Residential Supervisor will communicate with Manager of Facilities to put in a work order with the contractor of the agency to schedule and complete the repairs needed. 05/18/2026 Implemented
6400.171A plate containing prepared food was observed in the microwave oven. The food was removed during the inspection.Food shall be protected from contamination while being stored, prepared, transported and served. Staff immediately removed the plate during the inspection. Staff will be retrained on the proper storage of food, and the importance of ensuring that food is appropriately stored and saved to protect the food from any form of contamination. 05/18/2026 Implemented
SIN-00158981 Renewal 07/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(d)Individual #2 annual assessment dated 6/19/18 was not signed and dated until 7/12/18.The program specialist shall sign and date the assessment. On 7/29/19 the Residential Associate Director completed training with Program Specialist staff. This training addressed completion and signature of annual assessment. Documentation of training will be kept in staff files. For a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of residential consumers to ensure compliance with regulations. Documentation of quarterly reviews will be kept. 07/29/2019 Implemented
SIN-00112406 Technical Assistance 04/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(iv)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 08/29/2016 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF PERSONAL ADJUSTMENT.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
6400.181(e)(13)(v)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 08/29/2016 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF SOCIALIZATION.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
6400.181(e)(13)(vi)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 08/29/2016 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF RECREATION. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
6400.181(e)(13)(vii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 08/29/2016 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF FINANCIAL INDEPENDENCE. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
6400.181(e)(13)(viii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 08/29/2016 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF MANAGING PERSONAL PROPERTY. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
SIN-00067529 Renewal 09/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The top draw of Individual # 3's dresser was broken; the draw world not stay on its track. Furniture and equipment shall be nonhazardous, clean and sturdy. The dresser was repaired on 9/29/14. All staff, supervisors, maintenance personnel and management personnel have been retrained on ensuring that all areas of the home are in good repair and on timely reporting of any issues to the appropriate staff. See attached training sheets. Residential Managers will complete an outlined inspection of their sites on a monthly basis and submit checklist to their supervisor. Maintenance personnel will also complete an outlined inspection of their assigned sites monthly and submit the checklist to their supervisor. Please see attached checklists. Third Shift Supervisor has a revised nightly checklist to ensure all areas are checked thoroughly. Administrative staff conduct site inspections twice per month. See attached reports. See attached work order. 09/29/2014 Implemented
6400.168(a)Staff B who was hired on 1/1/14 administered medication during the month of September, yet has not completed the Department of Public Welfare's Medication Administration Training Requirements. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. The medication trainer was retrained by the Human Resources Manager on 9/30/14 to ensure that documentation of staff medication testing, trainings and observations are correctly and properly written on all forms and to ensure that staff names and dates are clearly written and accurate on all forms as the paperwork was missing the staff identifiers on some pages. See attached training sheet. The trainer will monitor all recall dates to ensure all staff are in compliance. The Human Resources Manager will monitor quarterly. 09/30/2014 Implemented
6400.168(d)Staff C's previous Medication Administration Practicum was completed on 4/30/13; the most recent practicum was completed on 5/22/14. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. The medication trainer was retrained by the Human Resources Manager on 9/30/14 to ensure that documentation of staff medication testing, trainings and observations are correctly and properly written on all forms and to ensure that staff names and dates are clearly written and accurate on all forms as the paperwork was missing the staff identifiers on some pages. See attached training sheet. The trainer will monitor all recall dates to ensure all staff are in compliance. The Human Resources Manager will monitor quarterly. 09/30/2014 Implemented
6400.186(c)(4)(iii)Individual 2's monthly summaries from October of 2013 through August of 2014 read exactly the same; no progress was noted; there was no documentation indicating that the program specialist recommended changes to the outcomes. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. The Program Specialists were retrained on 9/24/14 regarding ensuring that all outcomes remain appropriate for the individual and ensuring that if no progress is being made that they initiate making changes to the individuals plan. The Program Specialists will monitor through review of Monthly progress notes and will document any need for changes to outcomes in their quarterly reviews and in an email to the supports coordinator. The Manager of Residential Services will monitor through review of monthly and quarterly notes. 09/24/2014 Implemented
SIN-00222861 Renewal 04/11/2023 Compliant - Finalized
SIN-00211588 Renewal 04/12/2022 Compliant - Finalized