Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220516 Renewal 03/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was a leak in the basement near the entrance to the sprinkler closet coming from the ceiling.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, surfaces shall be in good repair; there was a leak in the basement coming from the ceiling near the sprinkler closet. A maintenance request was submitted on 3/14/23 by Director to repair the leak in the ceiling. Scheduled work to be completed by Maintenance department by 3/22/23. 03/17/2023 Implemented
6400.112(c)The evacuation times are unclear for several months. For example, the drill held on 10/28/22 lists an evacuation time of "152.93". The evacuation time needs to be clearly written in a time format that is able to be understood..A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The evacuation times are unclear for several months on the fire drill record (form). The time should be clearly written in a time format that is easily understood. All components of the fire drill record (form) must be completed during a fire drill. The fire drill records were corrected to reflect the time (length of time of evacuation) in a clear, understandable time format. The time was corrected on 3/15/2023 by the Director. The House Supervisor was retrained on the process of record keeping related to fire drills (specifically time format) by the Director on 3/15/23. 03/15/2023 Implemented
SIN-00182444 Renewal 02/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)A written summary of corrections for areas of non-compliance identified by the provider was not completed and/or available at the time of inspection. Areas of non-compliance identified on the self assessment were peeling leather chairs, missing trash can lid and bathroom needing cleaning. This issue was also observed for two homes not selected in the sample (2725 Woodland Avenue and 26 W. Mt. Kirk Avenue).A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The Director was trained in written summaries. The written summaries of corrections made for the self-assessments was written and completed on 2/11/21. The written summaries are filed with the self-assessments (Attachment #2). 02/11/2021 Implemented
6400.64(e)Two kitchen trash cans over 18 inches did not have lids.Trash receptacles over 18 inches high shall have lids. Trash receptacles over 18 inches high shall have lids. At the time of inspection, there were two trashcans in the kitchen that did not have lids on them and were not actively being used. Both lids were next to the trashcans and were immediately replaced at the time of inspection. Individual, JK likes to help by taking out the trash and recycling, but often forgets to put the lids back on the cans. The residential staff will remind the individuals and/or put the lids back on the kitchen trashcans upon returning from taking the trash or recycling outside. 04/15/2021 Implemented
6400.76(a)Furniture in the living room was worn and torn and needs replacing. Affected furniture includes one sofa and three recliner chairs. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture in individual bedrooms and family living areas shall be nonhazardous, clean and sturdy. The sofa and chairs in the living room was observed to be peeling. Three new recliner chairs were ordered on 2/23/21 and delivered to the house. (Attachment #3) 03/01/2021 Implemented
6400.82(f)Individual #1 bathroom did not contain a trash receptacle.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The bathroom in individual #1¿s room did not have a trash receptacle present during the time of inspection. The trashcan was placed back inside of the bathroom, at the time of inspection. The staff will continue to encourage individual #1 to keep his trashcan in the bathroom. He often rearranges his bedroom and bathroom; he needs reminders to keep the trashcan in the bathroom. 04/15/2021 Implemented
6400.101Snow was not plowed at the exit egress of the activity room and the patio.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Stairways, halls, doorways and exits from rooms and from the building shall be unobstructed. At the time of inspection, the snow in front of the exit from the activity room to the patio was not shoveled. The house supervisors were retrained in the regulations by the director on 3/24/21. 04/15/2021 Implemented
6400.112(c)Fire drill records for 9/19/20 and 10/18/20 did not indicate if any problems were encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. On the fire drill logs dated 9/19/20 and 10/18/20 there was no documentation if there were any concerns noted (i.e. N/A). The residential administrative assistant retrained all supervisors on 3/25/21 in the requirements needed for filling out a fire drill log. 04/15/2021 Implemented
SIN-00107141 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)There was no receipt in Individual #1's financial record for a disbursement of $200.00 on 10/06/2016. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. If the home assumes the responsibility of maintaining an individual's financial resources, the following will be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding 15.00 dollars made on behalf of the individual carried out by or in conjunction with a staff person. Do to a filing issue, receipts where separated from the log and found in the bottom of the filing drawer. All receipts will be required to be turned in an envelope to ensure they do not get separated. Attached is receipts and log. A full financial file review will be completed by the CRD Director by 4/15/2017. The Residential Coordinator will ensure receipts are secure in an envelope when turned in to the financial office for review and filing. 04/14/2017 Implemented
6400.67(a)The sliding shower door located in the hall bathroom would not slide and remained in a open position.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings and other surfaces will be in good repair. Door repaired on 1/30/2017. Staff will be retrained in the site safety checklist and their responsibility to ensure compliance by April 3, 2017. Supervisors responsible to ensure safety checklist are submitted and correct. CRD Director or ACRD Director will track non compliance and ensure corrected. Completed site safety for February 2017 attached . Attachment #10 04/28/2017 Implemented
6400.181(e)(2)Individual # 1's annual assessment dated 11/11/2016 did not document likes, dislikes or interests. The assessment must include the following information: The likes, dislikes and interest of the individual. The assessment will include the following information: The likes, dislikes and interest of the individual. Assessment was amended to include the likes, dislikes and interests. The program specialist was retrained in the required documentation for ISP compliance, including time frames for reports. CRD Director to conduct monthly reviews of individual's files. Attachment #9 03/21/2017 Implemented
6400.181(e)(12)Individual # 1's annual assessment dated 11/11/2016 did not document recommendations for training, programming or services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment will include the following information: Recommendations for specific areas of training, programming and services. The program specialist was retrained in the required documentation for ISP compliance, including the section on training, programming and services. time frames for reports. CRD Director to conduct monthly reviews of individual's files. Attachment #9 03/21/2017 Implemented
6400.181(e)(14)Individual # 1's annual assessment dated 11/11/2016 did not document the individual's ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The assessment will include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The program specialist was retrained in the required documentation for ISP compliance, including the section on water safety and ability to swim. CRD Director to conduct monthly reviews of individual's files. Attachment #9 03/21/2017 Implemented
6400.181(f)Individual # 1's annual assessment dated 11/11/2016 was sent to team members on 11/17/2016 and the ISP meeting was held on 12/12/2016.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The program specialist will provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP. The program specialist was retrained in the required documentation for ISP compliance, including time frames for reports. CRD Director to conduct monthly reviews of individual's files. Attachment #9 03/21/2017 Implemented
6400.186(b)Individual # 1's three month ISP review documentation dated 03/13/2016 was not signed by the program specialist or the individual. Individual # 1's three month ISP review documentation dated 09/13/2016 was not signed by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program specialist and individual will sign and date the ISP review signature sheet upon review of the ISP. The program specialist was retrained in the required documentation for ISP compliance, including the need for signatures. CRD Director is reviewing all assessments and providing feedback to program specialist. Attachment # 3. 04/03/2017 Implemented
6400.186(d)There was no documentation Individual # 1's three month ISP review documentation dated 03/13/2016 was sent to team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The program specialist will provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The program specialist was retrained in the required documentation for ISP compliance, including time frames for reports. CRD Director to conduct monthly reviews of individual's files. Attachment #9 04/28/2017 Implemented
SIN-00063498 Renewal 07/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff B's previous physical examination was dated 5/10/11. The most recent physical examination was dated 6/2/13 exceeding the 2 year requirement. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff physical examination will be completed every 2 years. Tracking system is in place via the Human Resources Department. Notification of physical exams being due will be sent in a email to the staff's supervisor. CRD Director monitors the completion of physicals with time frames on monthly basis. Additionally, a software sytem has been purchased to track all phyicals. This system was implemented on 7/14/2015. 07/14/2015 Implemented
SIN-00240603 Renewal 03/06/2024 Compliant - Finalized
SIN-00130365 Renewal 01/30/2018 Compliant - Finalized
SIN-00049760 Renewal 07/01/2013 Compliant - Finalized