Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279745 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notification to the local fire department dated 6/13/25 and 4/8/25 noted that five individuals reside in the home. At the time of inspection, it was noted that six individuals reside in the home and were recorded on fire drills completed in November, September and August of 2025. Notification to the local fire department shall be kept current.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. An updated letter was completed by the Residential Director and sent to the fire department which includes information on the location of the bedrooms, and the number of individuals who require assistance with evacuation. Copy attached. Completed 12/17/25. 12/18/2025 Implemented
SIN-00242457 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)An individual over the age of 18 shall have a dental examination at least annually. Individual #1 had a dental examination on 3/25/2019 but there was no documentation in the record to indicate that any dental examinations have been completed since that date.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The guardian to individual #1 was contacted by the Director of Nursing as the guardian is the person responsible for scheduling all the medical appointments. Guardian was informed of regulatory requirements. 04/29/2024 Implemented
6400.46(b)Staff #1 completed fire safety training on 10/26/2022 then not again until 11/18/2023 exceeding the required timeframe.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff training procedure regarding mandated training compliance was reviewed by People Operations Director and Training Manager 05/01/2024 Implemented
6400.165(g)3-month psychiatric medication reviews were not completed in the required time frame. Individual #1 had a medication review on 5/31/2023, then not again until 9/19/2023. There was no documentation in the record to show that any medication reviews were completed since 9/19/2023.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.During review it was noted that the individual was a ¿no show¿ for his appointment scheduled for 08/29/2023. This has been properly documented within the individual¿s electronic health record to note the reason for the missed appointment and note the rescheduled date of the appointment. ((Follow-up Med Monitoring completed 12/18/2023, & 4/15/2024. I have attached the documentation. -CH 5/17/243)) 04/29/2024 Implemented
SIN-00222523 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification to the local fire department dated 1/18/23 listed the addresses of four 6400 community homes and stated that "we currently have individuals with developmental disabilities residing at the homes located at..." Further noted was "Attached are updated floor plans indicating the location of any bedroom of any individual who requires assistance evacuating in the event of a fire." Three individuals residing in the home use wheelchairs and one individual utilizes a walker. The letter did not include the number of individuals who reside in the home nor did it include the mobility needs of the individuals in the home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The center¿s QI, Operations, and Facilities Maintenance team has revised its fire safety letter to include needs identified within the citation, but also the updated needs noted in the 03/15/2023 6400 RCG update. (Attachment: Updated fire safety letter with attachments) 05/01/2023 Implemented
SIN-00203492 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment is to completed within 3 to 6 months prior to the expiration of the expiration of the certificate of compliance. The expiration date for the certificate of compliance was 3/31/2022 and the Self-Assessment was completed on 2/01/2022.The 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. 2022-2023 self-assessment was completed on 02/01/2022. 01/01/2023 Implemented
6400.112(f)All fire drills held from April 2021 through March 2022 utilized the same exit; the front door.Alternate exit routes shall be used during fire drills. Fire Drills were conducted in the home in April & May of 2022. 05/30/2022 Implemented
SIN-00190152 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguisher in the attic was last inspected 11/2019, which exceeds the annual requirement. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. A replacement fire extinguisher was immediately brought to the home to replace the out-of-date fire extinguisher. 04/30/2021 Implemented
SIN-00263129 Renewal 03/11/2025 Compliant - Finalized