Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00167047 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was dirt on the oven.Clean and sanitary conditions shall be maintained in the home. Dirt and grease was cleaned from above the built in oven on 10/1/19. A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.64(b)There was mouse droppings found in the basement.There may not be evidence of infestation of insects or rodents in the home. Mice droppings were cleared from the above the steps in the attic on 9/12/19. (Attachment #16) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.112(g)The fire drills did not very the time of day, 8 of 12 drills were held between 4 pm and 4:30 pm (8/15/19-4:10 pm, 7/8/19-4:00 pm, 4/16/19-4:16 pm, 3/26/19-4:10 pm, 2/15/19-4:15 pm, 1/15/19-4:30 pm, 11/13/18-4:15 pm, 10/11/18-4:03 pm Fire drills shall be held on different days of the week and at different times of the day and night. Fire Drill form will be modified to ensure different times and locations are completed for monthly fire drills. Going forward, fire drill requirements will be documented and tracked monthly by the administrative office clerical staff and monitored by the Regional Director. 02/01/2020 Implemented
SIN-00123306 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Deodoant which indicated to contact poison control if imjested was found on top of individuual # 1's dresser.Poisonous materials shall be kept locked or made inaccessible to individuals.Individual #1¿s assessment has been updated to reflect that she can safely use personal hygiene products and store them in her bedroom 10/03/2017 (Attachment #28) The template for the annual assessment has been revised to prompt Program Specialist to clarify person¿s ability to safely use hygiene products and ability to safely use poisonous materials (Attachment #29) 10/10/2017 Implemented
6400.67(a)The main bathroom has paint chipping from the shower tiles and orange color stains cosistent with water rust stains.Floors, walls, ceilings and other surfaces shall be in good repair. The home is a rental property and delay in repairs is due to negotiating with the landlord. The shower tiles will be reglazed. 12/31/2017 Implemented
6400.71The nearest telephone numbers of the police and fire department were not included on the emergency telephone liist.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The template for emergency numbers posted by each phone has been revised to include the name and numbers for the nearest police and fire department for non emergencies (Attachment #13). 911 will still be posted for all emergency calls. 11/20/2017 Implemented
6400.76(a)The dresser located in individual's # 2's bedroom has scratches and chipped wood approximatly a foot in length on its top portion. Furniture and equipment shall be nonhazardous, clean and sturdy. A new dresser has been purchased and delivered to the home (Attachment #27) Any furniture considered hazardous should be noted on monthly residential safety checklists (Attachment #4) and monthly compliance checklists (Attachment #5) so furniture can be repaired or replaced in a timely manner. 10/28/2017 Implemented
6400.112(a)There was no documentation of a fire drill for November 2016. An unannounced fire drill shall be held at least once a month. The assistant trainer is responsible for tracking firedrills each month to ensure that all homes complete an unannounced drill as required. The assistant trainer will alert the Regional Director by the 20th of each month of any drills still not completed. The assistant trainer will notify the Associate Directors and Program Coordinators of drills needed to ensure drills are completed by the end of the month. The assistant trainer will send follow up emails on the 25th and last day of each month until all outstanding firedrills are turned in. All management staff were trained in fire safety and Delta¿s procedures on 10/13/2017 (Attachment #2) 10/13/2017 Implemented
SIN-00061214 Renewal 02/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The first floor full bath had mildew on the grout between the wall and tub.(a) Clean and sanitary conditions shall be maintained in the home. Bathroom tile grout was re-caulked on 2/19/14. Completed work order will be forwarded it your attention. Work orders are generated by the residential managers for all facility concerns. Project Directors are completing monthly compliance checklist to ensure on-going compliance with regulatory standards. 04/01/2014 Implemented
SIN-00047533 Renewal 03/27/2013 Compliant - Finalized