Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00179263 Renewal 11/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash receptacle located in the back yard had a broken lid which did not cover the trashcan and not in good repair.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.On 11/19/2020, Trashcan with receptacles replaced in backyard, Assistant Site Manager will complete monthly inspections to assure regulations are in compliance 11/19/2020 Implemented
6400.66The light at the front entrance was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 11/20/2020, Light in front of the home replaced. Maintenance department will complete monthly inspection to ensure that the light is work 11/20/2020 Implemented
6400.101The back door egress exiting the kitchen was obstructed by large trash cans posing a hazard.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 11/13/2020, the trash cans were removed immediately clearing the backdoor exit. Site manager will do monthly inspection during fire drills to ensure the exit remains clear. 11/13/2020 Implemented
6400.144At inspection, medication Tylenol 325 mg. for individual#1 was listed on the MAR but the medication was not in the individual's medication box.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. COMHAR Nurse notified immediately about missing medication, The Tylenol 325mg was reordered and placed in the medication box on 11/13/2020; also retraining for the proper documentation and placement of medication has been done on 12/11/2020 and 12/14/2020 for the nurses and Assistant Site Managers. 11/13/2020 Implemented
SIN-00103805 Renewal 09/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessments were dated with three different dates making it undeterminable when the self assessment was completed.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. Assistant Residential Directors will complete the self-assessment required under regulation 6400.15(a) for each COMHAR site 3 to 6 months prior to the expiration date of COMHAR¿s certificate of compliance on February 4. They will list only one date on that self-assessment, the date of completion of the self-assessment. The Lead Assistant Residential Director will monitor process and timeliness of completion. 12/21/2016 Implemented
6400.76(a)The headboard on the bed of individual #1 located in the bedroom was detached from the bedframe. Furniture and equipment shall be nonhazardous, clean and sturdy. The headboard for individual#1 was reattached by COMHAR¿s maintenance technician. The assistant site manager was retrained to observe for such situations and to report to maintenance as is appropriate and to record on monthly site check list. Further oversight/monitoring will be provided by the Site Manager. 12/21/2016 Implemented
SIN-00074309 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The second step from the top of the basement steps had an approximately six inch crack running lengthwise. Floors, walls, ceilings and other surfaces shall be in good repair. The second step was replaced following the inspection. The maintenance department staff will conduct monthly checks of the home to ensure that all surfaces are in good repair. Staff will be trained on the prompt reporting of maintenance repairs to the program specialist so that repairs can be made promptly. 09/18/2015 Implemented
SIN-00078439 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The second step from the top of the basement steps have a crack in the step which is approximately a 6 inches lengthwise, which has the potential to cause a tripping hazard. Floors, walls, ceilings and other surfaces shall be in good repair. Entire Stairtread was replaced by COMHAR maintenance. Non-slip surface was added to tread. Step was painted. Stairtreads will be checked for hazzards during quarterly site reviews by assistant site manager assigned to COMHAR locations. Any concerns will be reported to maintenance department, immediately. 05/20/2015 Implemented
SIN-00045801 Renewal 01/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)Only one exit route was used for monthly fire drill held November, 2011 to December, 2012.(f) Alternate exit routes shall be used during fire drills. All staff in all residential programs were re-trained to alternate exits used during fire drills. Residential Administrative Assistant or designee will collect and review site fire drills. Site Manager will be advised of anyy issues observed and initiate appropriate actions. A new form was developed to track alternate exits used. Implemented
SIN-00151122 Renewal 03/06/2019 Compliant - Finalized
SIN-00057027 Renewal 12/09/2013 Compliant - Finalized