Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218555 Renewal 01/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission, 2/24/22 received fire safety training on 2/25/22. 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. Program specialist will be responsible for completing Fire safety training, regardless of time of admission, Program Supervisor will review all intake paperwork to ensure that fire safety training was completed on the day of intake. 02/06/2023 Implemented
6400.141(c)(12)Individual #1's physical examination completed 2/16/22 did not address physical limitations. This field was left blank.The physical examination shall include: Physical limitations of the individual. Program Specialist will review all physical examination paperwork upon admission, annually, and will initial the physical examination paperwork to ensure that there are not any blanks. 02/06/2023 Implemented
SIN-00130306 Renewal 02/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The basement door leading into the garage had a dead bolt lock and a push locking mechanism on the doorknob preventing egress from the garage when engaged. The garage does not have a standard door.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 3/19/18 the dead bolt lock was replaced with a circular disc to cover up the hole in the door. The push locking knob was replaced with a regular knob handle that does not lock. A picture of the changes will be sent to [Licensing Supervisor] for reference. [Pictures of the aforementioned door received via email. Immediately, a designated staff person shall complete an onsite check of all community homes to ensure that stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed and there are not any locking mechanism on doors preventing egress from any part of the homes. Within 30 days of receipt of the plan of correction, a designated staff person shall educate all staff persons working in community homes that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. (AS 3/19/18)] 03/19/2018 Implemented
SIN-00089895 Renewal 02/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home was completed on 8/17/15; the agency's current certificate of compliance is from 9/1/15 to 9/1/16.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. The Office Coordinator has an event scheduled in her Outlook calendar starting in March where she can send out the self-assessments that will then be due by April 31. The ID/D Manager will track when they are received to ensure they are completed in a timely manner. 03/26/2016 Implemented
6400.106The furnace was inspected on 9/17/14 and then again on 10/28/15.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. The Office Coordinator set up a tracking spreadsheet to ensure the Facilities Department schedules furnace inspections in a timely manner. The tracking will be monitored by the Office Coordinator and Secretary and the scheduling will be sent out to the Facilities department 1 month ahead of the due date. [Immediately, the ID/D Manager will develop, implement, train staff and oversee a procedures to ensure all furnaces at all community homes are inspected and cleaned at least annually by a professional furnace cleaning company, procedures shall include a review of the written documentation and a system to ensure written documentation of the inspection and cleaning is kept and available for review and tracking. (AS 4/20/16)] 03/26/2016 Implemented
6400.186(a)Compliance was unable to be measured due to the date of the ISP review being reviewed with Individual #1 was not documented. The electronic signature of the Program Specialist for the 3 month reviews ending 2/17/15 and 5/17/15 were dated 6/10/15 and for the 3 month reviews ending 8/17/15 and 11/17/15 were dated 12/31/15.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A date line has been added to MYCS 3 month ISP Review after the individual¿s signature line. The 3month ISP Reviews will be monitored monthly by the Program Specialists at the sites. [Individual #1 signed and dated ISP review, 11/18/15 to 2/17/16 on 2/17/16. Program Specialist will complete ISP reviews for all individuals as required and ensure individuals sign and date the ISP reviews upon review. At least quarterly, the CEO will review a 25% sample of ISP reviews to ensure timeliness and required signatures and dates. Documentation of reviews shall be kept. (AS 4/20/16)] 03/26/2016 Implemented
6400.186(b)Individual #1 did not date the ISP review signature sheet upon review of the ISP reviews ending 2/17/15, 5/17/15, 8/17/15 and 11/17/15.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. A date line has been added to MYCS 3 month ISP Review after the individual¿s signature line. The 3month ISP Reviews will be monitored monthly by the Program Specialists at the sites.[Individual #1 signed and dated ISP review, 11/18/15 to 2/17/16 on 2/17/16. Program Specialist will complete ISP reviews for all individuals as required and ensure individuals sign and date the ISP reviews upon review. At least quarterly, the CEO will review a 25% sample of ISP reviews to ensure timeliness and required signatures and dates. Documentation of reviews shall be kept. (AS 4/20/16)] 03/26/2016 Implemented
6400.213(13)Individual #1's record did not include a copy of the psychological evaluation completed 4/23/1996.Each individual's record must include the following information: Copies of psychological evaluations, if applicable. Psychologicals will be collected and filed for all new residents prior to admission. This is a requirement on our Pre-Admission packet and will be monitored by the Program Specialist and Lead DSP> [Immediately, the program specialists will review all individual's record to ensure a copy of the psychological evaluation is present as required. At least quarterly reviews of individual records shall be completed by the program specialists or designated staff to ensure all individual records include the required documents including copies of psychological evaluations, if applicable. Documentation of record reviews shall be kept. (AS 4/20/16)] 03/26/2016 Implemented
SIN-00058973 Renewal 01/31/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1 had a signed statement of rights dated 2/1/2012 and 2/18/2013, which exceeds the annual time frame. (b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Staff have been instructed to review and sign Individual Statment of rights within 365 days of previous annual review. 01/31/2014 Implemented
6400.213(1)(i)None of the individuals' records include the individuals' sex, to denote the individuals' gender. Each individual's record must include the following information: (1) Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Face sheets for all individuals has been updated to include this information. 01/31/2014 Implemented
SIN-00200633 Renewal 02/17/2022 Compliant - Finalized
SIN-00169670 Renewal 01/23/2020 Compliant - Finalized