Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236966 Renewal 01/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)On 1/04/2024 Individual #1's January 2024 medication administration record did not include the diagnosis or purpose for any of the prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The MAR has been updated to include the purpose for each medication. Please see supporting documents. 01/18/2024 Implemented
SIN-00197700 Renewal 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual #1's last mammogram was completed on 10/19/20, exceeding the annual requirement. Individual #1 is 50 years of age or older.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Mammogram completed on 12/22/21 Program Manager and Program Specialist retrained on 12/28/21 on 6400.141(c)(8) 12/30/2021 Implemented
SIN-00055138 Renewal 10/10/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)There is no documentation to indicate that Staff #1 had first aid training on an annual basis. The documentation for first aid/CPR training completed on 3/14/12 does not have an expiration date. The CPR training completed on 2/12/13 indicates that CPR training only was completed.(i) 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. Site: 6400.46(i) The area of non-compliance will be brought into compliance by using the standard American Red Cross training documentation sheet. To ensure that this is being done, the HR Department will review the sign in sheet after every class to ensure everyone involved in the training signed in and all parts of the class were completed. This plan was implemented on October 25, 2013 (This was the first class after licensing). 11/01/2013 Implemented
6400.67(b)On 10/10/13, the air conditioning unit in Individual #1's bedroom window had a sharp, rusted edge measuring approximately one foot in length. (b) Floors, walls, ceilings and other surfaces shall be free of hazards.Site 6400.67(b) Target Date: 11/29/13 House managers will do a walkthrough weekly to assure that floors, walls, ceilings and other surfaces shall be free of hazard. If they are not House manger will immediately report this to the maintenance department to be fixed as soon as possible. [The air conditioner with the sharp edge has been removed. (CHG 11/5/13)] 11/29/2013 Implemented
SIN-00143998 Renewal 10/23/2018 Compliant - Finalized
SIN-00086297 Renewal 11/03/2015 Compliant - Finalized