Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220722 Renewal 03/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 3/8/23 at 1:11PM, the hot water temperature, at the bathtub in the bathroom on the second floor of the home, measured 126.5F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Corrective Action: On 3-8-23 a mixing valve was installed on the hot water to prevent water temperature from reaching 120. Monitoring of the water temperature after the mixing valve was installed demonstrated a reading of 116 degree F. 03/09/2023 Implemented
6400.46(d)Direct Service Worker #1's cardio-pulmonary resuscitation and first aid training was for the "Child CPR" module and not include certification for adult cardio-pulmonary resuscitation and first aid training.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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Corrective Action Staff person Direct Service Worker #1 completed Adult First Aid/CPR/AED certification through the American Red Cross Training Services on March 13, 2023. 03/13/2023 Implemented
SIN-00150940 Renewal 02/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 11-10-18 had an evacuation time of 2 minutes and 38 seconds. The home does not have an extended evacuation time specified in writing by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Managers and Program Specialist were retrained on the fire drill process. All fire drills will be complete by the 15th of the month. The exists will be alternated and the evacuation time will be under 21/2 minutes to ensure compliance. If the drill is not accurate another drill will be completed by the end of the month to remain in compliance. [NOT ACCEPTABLE, fire drill can not be scheduled for specific days of the month, all fire drills are required to be unannounced. Immediately, the CEO or Designee shall develop a reporting procedure to follow if problems are encountered including when fire drills are not conducted in the required amount of time. Evaluation of problems encountered shall be conducted and addressed by management staff persons within 1 week of the fire drill. Within 60 days of receipt of the plan of correction, the CEO or Designee shall educate all staff persons responsible for conducting, auditing and evaluating fire drills of the requirements of fire drills as per 6400.112(a)-(I) and the procedures to report fire drill when problems are encountered. Documentation of trainings shall be kept. At least quarterly, a designated management staff person shall audit a 25% sample of all fire drill records to ensure fire drills are held and documented and reported as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/4/19)] 03/18/2019 Implemented
SIN-00239589 Renewal 02/13/2024 Compliant - Finalized
SIN-00201561 Renewal 03/08/2022 Compliant - Finalized
SIN-00089323 Renewal 02/04/2016 Compliant - Finalized