Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00177447 Renewal 10/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed and explained individual rights on 2/1/20. The rights document did not include the following rights: 6400.31(b) The home shall educate, assist to make choices and understand the individual's rights; 6400.31(c) Individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; 6400.31(d) A court's written order that restricts an individual's rights shall be followed; 6400.31(e) Court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 6400.31(f) An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 6400.32(g) An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual; 6400.32(d) through 6400.32(h) Individual shall be treated with dignity and respect, choose, accept risks, refusal and control the individual's schedule, activities and services, privacy and access to person and possessions; 6400.32(n) Unrestricted and private access to telecommunications; 6400.32(p) through 6400.32(u), choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, locking doors in bedrooms and in the home, access to food at any time, and making healthcare decisions.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Supportive Living Services (SLS) Individual Rights document was updated to reflect the exercising of rights and individual rights as documented in chapter 6400.31 and 6400.32 regulations. The SLS Policy and Procedure was also updated to reflect chapter 6400.31 and 6400.32 regulations. The SLS Individual Rights document will be reviewed and completed by Individual #1 and all individuals receiving residential service at SLS by 11/21/20. In addition the SLS Individual Rights document will be reviewed with individuals upon admission and annually with every individual. The Individual Rights document will be reviewed by the assigned Program Specialist or SLS designee with the individual and other identified team members as necessary. 11/21/2020 Implemented
SIN-00136253 Renewal 06/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self assessment completed for this home was not dated; therefore, compliance could not be measured.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. 1. Updated Lii¿s to be reviewed with the team once available from ODP. (upon release) 2. Instructions for completion will be reviewed at that time also. Instruction will be given to put name and dates at the time of inspection. 3. Team will discuss the specific sections of the Lii that they are responsible to complete prior to the pre-inspection phase in February of 2019. [Upon receipt of the current Certificate of Compliance, the CEO or designee shall develop a tracking system to ensure timely competition of the self-assessment. Prior to 3 month of the expiration date, the CEO or designee shall audit all self-assessment to ensure completion to include all required information included the date of competition to ensure timely completion. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for completing and auditing self-assessment of all of the aforementioned processes. Documentation of audits shall be kept. (AS 7/17/18)] 02/05/2019 Implemented
6400.112(a)An unannounced fire drill was not held in March 2018. An unannounced fire drill shall be held at least once a month. 1. Review expectations for managers completing unannounced fire drills (Program Specialists) 2. Managers will complete unannounced monthly fire drills each month of the year (Resident Managers 3. Managers will route documentation of each unannounced drill to the program specialists upon completion for review (Upon receipt of completed drill) 4. Program Specialists have new checklist to review and ensure that they have received all monthly documentation required from the managers each month (Upon receipt of documentation) 5. Program Specialists will monitor and contact managers if the paperwork is not received by the 20th of every month to ensure drill has occurred (Monthly on the 20th) [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate of staff persons responsible for conducting, documenting and auditing fire drills of the requirement of fire drill as per 6400.112(a)-(I) and the aforementioned procedures to ensure fire drills are conducted and documented as required. (AS 7/17/18)] 07/10/2018 Implemented
SIN-00060316 Renewal 02/26/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dryer hose/vent contained an excessive amount of lint which presents a fire hazard. Three handfuls were able to be pulled out of the vent.(a) Furniture and equipment shall be nonhazardous, clean and sturdy. The dryer vent was cleaned out on 02/26/2014. Staff will be trained in the importance of routine household maintenance. 02/26/2014 Implemented
6400.82(e)The bathtub in the shared bathroom located in the hallway does not have an anti-skid mat or surface.(e) Bathtubs and showers shall have a nonslip surface or mat. Bathmat was purchased and in place by 03/07/2014. Staff will be trained in the imprtance of basic safety measures in the home 04/10/2014 Implemented
SIN-00209538 Renewal 08/10/2022 Compliant - Finalized
SIN-00117613 Renewal 06/28/2017 Compliant - Finalized
SIN-00041352 Renewal 10/01/2012 Compliant - Finalized