Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242925 Renewal 04/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)Staff #1, Staff #2 and Staff #3's annual fire safety training was completed late. Staff #1 completed fire safety training on 10/7/22 and did not complete it again until 10/26/23. Staff #2 completed fire safety training on 10/7/22 and did not complete it again until 10/11/23. Staff #3 completed fire safety training on 10/3/22 and did not complete it again until 10/12/23.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The staff were informed that fire safety will now be due twice a year, in the months April and October. All staff assigned to Sanderson have completed fire safety in April 2024, to ensure compliance going forward. 04/30/2024 Implemented
SIN-00222515 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186At the time of the physical site inspection there was several sharp's throughout the facility. There were 2 pair of large scissors in the kitchen drawer, along with a large round pizza cutter which were all easily accessible. In addition, there was other sharps/scissors located in other program rooms. The individual ISP and her initial skills assessment dated 4/12/23, reflect that due to her history of self-harm that poisons and sharp objects are locked to assure the safety of herself and others. The ISP is not being implemented at this time.The facility shall implement the individual plan, including revisions.The initial assessment was written incorrectly. It noted that all sharps were locked, this was incorrect. The skill assessment was updated on 4/21/2023 to reflect Individual #1's accurate needs, which include that Individual #1 is supervised by her staff while in the activity room that offers the cooking class. Also, the activity room that offers the cooking class is locked when not in use. The SC had the updated skill emailed to her on 4/21/2023 The SC was also reached by phone on 4/24/2023. 04/21/2023 Implemented
SIN-00104057 Renewal 12/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #2 had an annual assessment on 12/23/2014. He did not have another assessment until 1/15/2016, which exceeds the annual requirement. Individual #3 had an annual assessment on 6/19/2015. He did not have another assessment until 7/14/2016, which exceeds the annual requirement. Individual #4 had an annual assessment on 3/4/2015. She did not have another assessment until 3/22/2016, which exceeds the annual requirement. Individual #5 had an annual assessment on 1/9/2015. She did not have another assessment until 5/11/2016, which exceeds the annual requirement. Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The vocational case managers have developed a tracking sheet that will be utilized to track assessment dates. This will ensure timely completion of each individual¿s annual assessment in order to maintain compliance with regulation 2390-151(a). The tracking sheet will be maintained by the Vocational Case Managers and reviewed monthly by the Vocational Coordinator. The assigned vocational case managers have been trained on this new process. 01/31/2017 Implemented
SIN-00087523 Renewal 12/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Fire safety training was not completed for 5 individuals in 2015. Individuals #8, #9, #10, #11, and #12 had their last fire safety training on 10/31/2014.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Fire safety training has been reviewed with the adults listed above: Individual #1 - 11.16.15,Individual #2- 11.13.15,Individual #3- 11.13.15, Individual #4- 11.13.15, Individual #5- 11.13.15 . An individual trainee fire safety form will be completed by Program Specialists, annually and upon admission. This will be placed in their respective file so that the Program Specialist is able to ensure tracking and annual documentation. 11/16/2015 Implemented
2390.156(c)(2)The Quarterly Reviews of the Individual Support Plans (ISP) for Individuals #1, #2, #3, #4, #5, #6, and #7 do not contain a review of each section of the ISP specific to the facility. The areas of safety, health, and supervision needs are not addressed in quarterly reviews. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist meeting held on 11.18.15 to review changes and training on the additional Health/Safety/Supervision section added to the quarterly reviews to ensure compliance. 11/18/2015 Implemented
SIN-00051304 Renewal 07/17/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(2)The assessments for Individual 1 and Individual 9 did not include likes, dislikes, and interests. (e) The assessment must include the following information: (2) The likes, dislikes and interest of client, including vocational and employment interests of the client.The assessment was modified to include the likes/dislinkes and interests of the client, including the vocational and employment interests. -Fully Implemented CH 8/13/13 07/17/2013 Implemented
2390.151(e)(4)The assessments for Individuals 1,2,3,4,5,6,7,8,9 did not include supervision needs for the vocational program.(e) The assessment must include the following information: (4) The client's need for supervision.The assessment was modified to include the client's supervision needs. -Fully Implemented CH 8/13/13 07/17/2013 Implemented
2390.151(e)(5)The assessments for Individual 1 and Individual 9 did not include the ability to self-administer medications.(e) The assessment must include the following information: (5) The client's ability to self-administer medications.The assessment was modified to include the client's ability to self administer medications -Fully Implemented CH 8/13/13 07/17/2013 Implemented
2390.151(e)(6)The assessments for Individual 1 and 9 did not inlcude the ability to use or avoid poisonous materials.(e) The assessment must include the following information: (6) The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The assessment was modified to include the client's ability to safely use or avoid poisonous materials -Fully Implemented CH 8/13/13 07/17/2013 Implemented
2390.151(e)(7)The assessments for Individual 1 and Individual 9 did not include knowledge of the danger of heat sources.(e) The assessment must include the following information: (7) The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The assessment was modified to include the clien'ts knowledge of the danger of heat sources and the ability to sense and quickly move away from heat sources in escess of 120 F that are not insulated. -Fully Implemented CH 8/13/13 07/17/2013 Implemented
2390.151(e)(8)The assessments for Individual 1 and Individual 9 did not include the ability to evacuate during a fire.(e) The assessment must include the following information: (80 The client's ability to evacuate in the event of a fire.The assessment was modified to include the client's ability to evacuate in the event of a fire. -Fully Implemented CH 8/13/13 07/17/2013 Implemented
SIN-00204470 Renewal 05/13/2022 Compliant - Finalized
SIN-00189514 Renewal 05/24/2021 Compliant - Finalized
SIN-00153969 Initial review 04/18/2019 Compliant - Finalized
SIN-00142842 Renewal 11/20/2018 Compliant - Finalized
SIN-00129745 Renewal 12/27/2017 Compliant - Finalized
SIN-00068190 Renewal 09/15/2014 Compliant - Finalized
SIN-00067061 Renewal 08/27/2014 Compliant - Finalized