Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226509 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 10/19/22 did not assess compliance with the following regulations: 6400.32s3, 6400.32t, 6400.34a, 6400.34b, 6400.211b4, 6400.212, 6400.212b, 6400.213(1)i -- 6400.213(1)vi, 6400.213(3) -- 6400.213(5), 6400.213(7), 6400.213(8), 6400.214a -- 6400.214c, 6400.215a, 6400.216a -- 6400.216b, and 6400.217.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. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation -- 7/11/22) The self-assessment for the home completed on 10/19/22 did not include a written summary of corrections for 6400.51b5.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. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
SIN-00137755 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill was conducted on 9/9/17 and not again until 4/24/18.A fire drill shall be held during sleeping hours at least every 6 months. 112 (e): Immediate: A fire drill was conducted during sleeping hours on 4/24/2018 once it was discovered that the deadline was missed. Global Immediate: Associate Director of Operations provided a retraining to Program Managers and Program Coordinators on 8/28/2018 regarding the necessity of completing fire drills during sleeping hours at each required 6-month interval to ensure that Individuals respond in varied conditions during an emergency. Global Preventive: The Associate Director of Operations Team shall implement a task system utilizing Microsoft Outlook on or before 10/23/2018 relating to fire drills with a feature associated to remind each Program Manager at 6-month intervals to complete a fire drill during sleep hours. Each Program Manager and Program Coordinator shall acknowledge the fire drill and smoke detector/extinguisher checks as appointments on their Outlook calendars within 2 business days of appointments being received by the Associate Director of Operations Team. Adherence to this schedule shall be monitored and documented by Program Coordinators on at least a monthly basis. 10/23/2018 Implemented
SIN-00076711 Renewal 02/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected on 9/12/13 and not again until 10/16/14.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furance inpsections for fairview home was completed on 10/16/2014. All other homes are in compliance as of date of licensing inspection. updated tracking tool for monitoring of furnace inspection dates was developed on 12/31/2014 to ensure ongoing compliance. Implemented
6400.151(a)Staff #1 had a physical on 1/16/13 and had not had one since. She was due for her physical on 1/16/15. Annual inspection was conducted on 2/18/15. 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 #1 was taken off shift coverage immediatly on 2/20/2015. Team members returned to work on 2/25/2015 when completed employee physical including a TB test was obtained. All team member records were reviewed by the human resources department on 2/24/2015 to verify regulatory compliance. At that review, all Tm records were updated to ensure regulatory complaince. a quarterly review of team members physical exam dates will occur to ensure regulatory compliance. Implemented
6400.151(c)(2)Staff #1 had a TB on 1/14/13 and had not had one since. She was due for her TB on 1/14/15. Annual inspection was conducted on 2/18/15. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff #1 was taken off shift coverage immediately on 2/20/2015. Team member returned to work on 2/25/2015 when completed employee physcial including a TB test was obtained. All team members records were reviewed by the human resources, department on 2/24/2015 to verify regulatory complaince. at that review, all TM records were updated. A quarterly review of team member physical exam dates will occur to ensure regulatory compliance. Implemented
SIN-00191545 Renewal 08/10/2021 Compliant - Finalized