Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00208820 Renewal 07/27/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 7/27/22 at 2:10PM, the bathroom behind the stairwell in the basement of the home did not have mechanical ventilation and the window was unable to be opened.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. CLC Maintenance team fixed the window in questions so that it was operable and could be opened. This occurred on the day of the inspection of PA Ave (July 27, 2022). [Picture provided to ODP via email]. 07/27/2022 Implemented
6400.66On 7/27/22 at 2:15PM, the light fixture containing a light bulb in the ceiling near the stairwell in the basement of the home stairwell did not illuminate. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. CLC Maintenance team fixed the light fixture in questions so that it was operable. This occurred on the day of the inspection of PA Ave (July 27, 2022). [Picture provided to ODP via email]. 07/27/2022 Implemented
SIN-00093790 Renewal 04/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Indivdual #1's record did not include color of hair, color of eyes, identifying marks and religious affiliationEach individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.(Michele Britt)MB¿s Emergency Medical Information (EMI) form was update to include the missing information of hair color, eye color, identifying marks and religious affiliation. (EMI for MB sent to licensing 5/13) EMI forms for all 57 individuals in the residential program have been reviewed. Three were found to have the identifying marks field incomplete (TZ, ML, CP); another 5 were missing religions affiliation (JS, ML, DM, JC, JS). (EMI for these folks sent 5/13). The functionality of the EMI form is being updated to include the print function to be enabled only once all required fields are complete / have something typed into them. (Verification will be sent by July 1, 2016) 05/12/2016 Implemented
SIN-00041244 Renewal 10/31/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101RNC - The closet in the bathroom has a padlock on the door obstructing egress. Fully Implemented - PE - 2-14-13Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Staff at the site and all DSS Supervisors have been retrained on 12/6/12 in reporting unsafe conditions via Work Orders immediately to the Maintenance Director on physical site. Included in the DSS Supervisor training was an emphasis on this particular violation, which consisted of a padlock on a closet door. All DSS Supervisors have been retrained again on non-compliance issues with regard to padlocks and have been aware that any area large enough for a person to be placed into or get into cannot be locked. The Residential Director is responsible for this training. A monthly checklist has been created for maintenance staff to inspect and insure all areas of compliance with regards to interior and exterior physical site and safety for all residents who reside within the sites. A daily checklist has been developed for DSS Supervisors and staff to complete and monitor all areas of compliance with regards to interior and exterior.Any non-compliances if found will immediately be placed on a Work Order and sent to the Maintenance Director so repair/modifications can be made. The Maintenance Director is responsible for making all corrections to bring site back into compliance as Work Orders are received or non-compliances are observed by maintenance staff expeditiously. 12/13/2012 Implemented
6400.141(a)The physical examination for Individual #1 was not completed annually. The current physical is dated January 27, 2012 and the previous physical examination was dated January 5, 2011. Fully Implemented - PE - 2-5-13(a) An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The DSS Supervisor has been retrained on 12/6/12 in insuring dates are secured for annual physical exams that allow the individual to remain in compliance with 6400 Regulations. DSS Supervisors have been instructed to secure appointments for annual exams at least one month before they are due and turn these dates into the appropriate Program Specialist, who will assist in tracking to insure compliance. Two physicals have been included in the hard-copy packet to demonstrate compliance since this violation. 12/13/2012 Implemented
6400.186(b)The three month Individual Support Plan reviews for Individual #1 for July through September 2012, April through June 2012, January through March 2012 and October through December 2011 were not dated by Individual #1 and Staff #1. Partially Implemented - Adequate Progress - PE - 2-14-13(b) The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. partially implemented PE 2-5-13Both Residential Program Specialists have been retrained on 12/6/12 on insuring that all ISP Reviews are done within 3 months of the prior ISP Review and, upon completion, are signed and dated by the appropriate Program Specialist and Individual. Tbe Program Specialists have also been made aware that, within 30 days of the completion of each Individual Review, it is the Program Specialists' responsibility to insure that the Reviews are disseminated to all team members unless a member has acknowledged that he or she does not want the review. This training was done by the Residential Director. A hard-copy of a blank ISP Review will be enclosed in the POC packet to demonstrate compliance. No ISP Reviews are due to be completed until January 2013 at which time we will forward a completed packet on to the appropriate licensing representative. Two Individuals Three month ISP Reviews were completed and submitted. 12/13/2012 Implemented
SIN-00154606 Renewal 04/30/2019 Compliant - Finalized