Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228636 Renewal 08/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The home contained unlocked poisonous materials including nail polish remover.Poisonous materials shall be kept locked or made inaccessible to individuals. For corrective action and clarification purposes, we have included the Individual Support Plans (ISPs) for all individuals residing at the Raymond home (attachment). 09/07/2023 Implemented
SIN-00172452 Renewal 03/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)Outside the building the wheelchair deck was not free from unsafe conditions, there were exposed nails throughout and there were loose boards located on the floorboard of the deck. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.1. The deck was repaired by maintenance on 3/17/2020 to address immediate safety concerns of exposed nails and loose floorboards. (Attachment #28) 2. The remainder of the work, including staining, will be completed by July 31 2020. The Director of Maintenance will be responsible in ensuring successful completion. 3. On a weekly basis, the Cluster Lead staff (newly created position) will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with environment checks under the supervision of the cluster Team Facilitator. (PA-QA Attachment #1) 4. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #2) 5. If an area of non-compliance is identified, a Maintenance request will be completed by the lead staff, Team Facilitator or designee. 6. All Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding environmental checks. This training will be completed by the Associate Residential Directors. 7. This training will be completed by July 31, 2020. 07/31/2020 Implemented
6400.82(e)The bathroom shower located on the main floor did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. 1. A shower mat was replaced on 3/14/2020. (Attachment #27) 2. Direct support professionals will be re-trained on the dangers of not having non-slip mats in the bathrooms. In case the condition of the non-slip mat deteriorates, the DSP¿s will purchase a new non-slip mat using petty cash in the home. The training will be completed by the Team Facilitator or designee. 3. On a weekly basis, the Cluster Lead staff (newly created position) will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with environment checks including presence of non-slip mat in every bathroom. (PA-QA Attachment #1) 4. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #2) 5. If an area of non-compliance is identified, a Maintenance request will be completed by the lead staff, Team Facilitator or designee. 6. All Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding environmental checks. This training will be completed by the Associate Residential Directors. 7. This training will be completed by July 31, 2020. 07/31/2020 Implemented
SIN-00126890 Renewal 12/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)THERE WAS PEELING PAINT AROUND THE VENT IN THE CEILING IN THE BASEMENT. ALSO THERE WERE SEVERAL KNOBS MISSING FROM INDIVIDUAL #1'S DRESSER, CHEST, AND NIGHT STAND.Floors, walls, ceilings and other surfaces shall be in good repair. The painting around the vent on the basement ceiling was completed 1/18/18 (see attachment #14). Maintenance request was submitted on 1/18/18 to repair the knobs missing from the Individual #1¿s dresser, chest and night stand (see attachments #15-17) .The Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to checked, how often and who will complete the task. The checklist will be completed by 3/31/18. 01/18/2018 Implemented
6400.77(b)THE FIRST AID KIT DID NOT CONTAIN SCISSORS. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 1. Scissors were replaced in First Aid Kit on 12/14/17 (see attachment #13) 2. An overnight shift checklist to be used by DSPs on every night shift will be developed, and training done for all DSPs. The checklist will cover items that staff will look for and what actions to take if items are missing. The Team Facilitator will monitor if the daily checks are done and document on a weekly basis. This checklist will be completed by 3/31/18 12/14/2017 Implemented
SIN-00113391 Renewal 12/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed on 09/29/2015 and the certificate of compliance expired on 03/30/2016The 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. Cluster Administrators and Associate Director for oversight will initiate the self-assessment tool 6 months prior to the expiration date of the license and document date on the self- assessment check list. 05/01/2016 Implemented