Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258499 Renewal 01/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual fire safety training last completed for Individual #4 in 2023.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.During the inspection of participant records, it was discovered that Participant # 5 did not have documented evidence of fire safety training in 2024. SpArc takes fire safety training seriously and completes training multiple times a year to ensure that program participants receive the training and know how to respond in emergency situations. An internal audit was initiated due to the missing documentation and revealed that participant #5 was in attendance at SpArc on June 26, 2024 when fire safety training took place, however due to an oversight, participant #5 did not sign the training form. On 1/30/2025 The Director of Program Administration reviewed the fire safety training with participant #5 (attachment #1 ). 01/30/2025 Implemented
2390.21(u)Rights are past due with the initial signing date occurring on 3/15/23 for Individual #1. Rights are past due with the last signing occurring on 3/31/22 for Individual #2. Rights are past due with the last signing occurring on 1/31/22 for Individual #3. Rights are past due with the initial signing date occurring on 8/15/23 for Individual #4. Rights are past due with the last signing occurring on 2/2/23 for Individual #5. Right are past due with the last signing occurring on 2/25/22 for Individual #6. Right are past due with the last signing occurring on 1/31/23 for Individual #7. Right are past due with the last signing occurring on 11/17/23 for Individual #8. Right are past due with the last signing occurring on 2/2/23 for Individual #9. Right are past due with the last signing occurring on 2/6/23 for Individual #10. Right are past due with the last signing occurring on 4/4/22 for Individual #11. Right are past due with the last signing occurring on 11/19/23 for Individual #12.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.During inspection of participant books, it was discovered that ¿Participants Rights¿ were signed in 2023 but not in 2024. This is an updated version of the participant rights regulation and prior to 2021 it was only signed at the onset of services. Upon learning of this requirement, the Director of Program Administration immediately composed a new Participant Rights waiver form with multi-year signature line (attachment #3). The on-site inspectors reviewed the new waiver form and approved. The Participant Rights will continue to be reviewed with participants and their families at the time of program admission and annually thereafter with the program specialists. In an effort to ensure that all program participants review the Participants Rights form, the program specialists have met with their entire caseloads, including individuals #1-#12, to review the participants rights (attachment #4). 02/13/2025 Implemented
SIN-00236993 Renewal 01/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(d)There were no tweezers found in the first aid area in cultural arts area - 2nd floor.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.During the walkthrough, two first aid kits on the second-floor cultural arts area were inspected. The first kit in the program area was compliant and had all the required contents. It was found that the second kit in the first aid area was missing a pair of tweezers. On 1/3/2024 all SpArc first aid kits had been inspected by SpArc¿s nurse and were found to be compliant, however, there were missing tweezers in one kit on 1/5/2024 during the inspection. It is important to SpArc to ensure that all first aid kits remain compliant at all times to ensure that adequate supplies is available during an emergency. Immediately after the inspection, the COO placed an order for new tweezers (Attachment #1) and they were placed in the first aid kit on the following program day, Monday, 1/8/2024. 01/08/2024 Implemented
SIN-00217675 Renewal 01/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The door leading to the outside in the back corner of the cultural center work space was unable to be closed and opened completely. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The door leading outside in the back corner of the Cultural Arts program was found to be damaged and unable to close completely. The Director of facilities addressed this issue immediately and fixed the door on the same day of the inspection, 1/11/2023 (Attachment#1). 01/11/2023 Implemented
2390.101Individual #1 became Covid positive in 2022 and was out of program from 8/3/22 until 8/12/22. There was no documentation showing that it was clear to return to work.Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.Individual #1 tested positive for Covid-19 and stayed home for the duration of their quarantine, 8/3/22 through 8/12/2022 in accordance with the CDC and SpArc¿s Covid-19 policy. In accordance with 2390.101, SpArc updated the SpArc Services Covid-19 plan to include the requirement of a doctor's note to return to the program after a person tests positive for Covid-19 and completes their quarantine (Attachment#2). 01/12/2023 Implemented
2390.124(3)Individual #2's record contained a data sheet where the physicians name area was left blank.Each client's record must include the following information: The name and telephone number of a physician or source of health care.During the inspection it was found that individual #2 did not have a physician¿s name on their face sheet. This was a printing error as the physician¿s name and contact was listed in the digital record, but had not printed. During the inspection the updated face sheet with the correct information was sent to the inspector on 1/11/2023 (Attachment#3). 01/11/2023 Implemented
2390.21(a)The client rights form has not been updated to include the new regulatory requirements.An individual may not be deprived of rights as provided under subsections (b) - (q).During the inspection it was found that the participants rights form had not been updated to include the new regulatory requirements. The Participant Rights document was updated on 1/23/2023 and shared with program specialists on 1/27/2023 (Attachment#5). Program Specialists were expected to meet the participants on their caseloads, read and explain their rights, have the program participants sign the new participants rights form, and send home copies of the new form to the participants' families and/or caregivers (Attachment#6). 01/23/2023 Implemented