Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226512 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 11/11/22 did not assess compliance for 6400.50a.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 11/11/22 did not include a written summary of corrections for the following violations: 6400.46d and 6400.151c2.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-00191546 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1's current, 10/21/20 fire safety training did not include documentation that they received training on the evacuation procedures. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individual #1, #2, and #3 shall receive fire safety training, including their responsibilities by 9/22/21. Associate Director of Operations shall develop a standardized Fire Safety Training template that includes general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home by 9/24/21. All Program Managers shall implement the standardized template within their program and update it to include all necessary and current information for the Individuals residing in that program by 10/21/21. 09/23/2021 Implemented
SIN-00137758 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The individuals residing in this home are not assessed to be safe with cleaning supplies. Resolve, Lysol and antibacterial gel were unlocked and accessible in laundry room cabinet.Poisonous materials shall be kept locked or made inaccessible to individuals. 62 (a): Immediate: The cabinet containing poisonous cleaning products (Lysol, Resolve and antibacterial gel) was immediately latched and locked upon discovery on 8/22/2018. A Maintenance Team Member shall assess and repair the cabinet door to assist in ease of closure as necessary on or before 9/23/2018. Global Immediate: Programs Managers shall review each Individual¿s assessment regarding poison safety and confirm compliance via email to Associate Director of Operations on or before 9/23/2018, following a thorough check within each facility to ensure adherence including any actions taken to address non-operative locks or other noted concerns, as applicable. Global Preventive: Associate Director of Operations provided retraining on 8/28/2018 regarding the requirement to maintain safety measures related to poison safety at all times within each facility, as identified in each Individual¿s ISP and Individualized Assessment. Program Managers shall provide retraining to Direct Support Professionals via the Communication Log within each program regarding poison safety, including the need to report any physical site issues that may compromise the Individual¿s poison safety needs, such as non-operative locks, on or before 9/23/2018. 09/23/2018 Implemented
SIN-00076714 Renewal 02/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Staff #4¿s first day working with individuals was on 5/28/14. She did not receive orientation to daily operations of the home until 5/29/14.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. review of all employee orientation records will be completed by 5/8/2015 to ensure compliance. House training checklist will be to prompt completion prior to contact with the individuals. Implemented
6400.46(i)Staff #4¿s date of hire was 5/20/14. She did not receive CPR training until January 2015.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Documentation of compliance with CPR/FA was obtained on 2/25/2015 and provied to licensing team on 2/20/2015. additional copy will be attached to POC. A tracking system will be devleoped and maintained. Implemented
6400.103The written evacuation procedure did not contain the Individuals¿ responsibility. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. individual's responsiblity was corrected 5/8/2015 for the timberline drive evacuation procedures. All homes will be verified by that supervisor to assure that individual's responsiblity is noted on evacuation procedures. A copy of updated evacuation procedures for timeberline drive will be provided. Implemented