Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279750 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notification to the fire department is not current. The notification to the fire department was not updated when the census of the home changed from 2 to 1.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. A 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-00242465 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Documentation of a fire drill conducted on 3/13/24 at 12:30AM with an evacuation time of 10 min 36 sec. did not include problems encountered during the drill that resulted in the drill being unsuccessful. Documentation of a second fire drill conducted on 3/13/24 at 11:15PM with an evacuation time of 5 min 34 sec did not include problems encountered during the drill that resulted in the drill being unsuccessful.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 3/13/2024 fire drill report was corrected utilizing the information sent to the operations teams regarding reason for non-compliance. (Attachment 12a: Update drill form, Attachment 12b: Re-run drill to show compliance) 05/01/2024 Implemented
6400.165(a)Prescription medications are not prescribed in writing by an authorized provider. The first aid kit contained a packet of non-aspirin that is not prescribed to any individual in the home.A prescription medication shall be prescribed in writing by an authorized prescriber.Pack of non-aspirin was removed during ODP physical site walkthrough on 04/02/2024. 04/02/2024 Implemented
SIN-00203485 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/30/21 to 12/31/21, and the self- assessment was dated 2/1/22. This exceeds the requirement.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
SIN-00263143 Renewal 03/11/2025 Compliant - Finalized
SIN-00222520 Renewal 03/28/2023 Compliant - Finalized
SIN-00190156 Renewal 04/20/2021 Compliant - Finalized