Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214589 Renewal 11/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Leftover pizza bites were found in the air fryer basket in the kitchen.Clean and sanitary conditions shall be maintained in the home. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that food is properly disposed and not left out per regulatory guidelines. 11/10/2022 Implemented
6400.82(e)There was no non-slip mat in the shower area. Bathtubs and showers shall have a nonslip surface or mat. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that every bathroom has a nonslip surface in the shower. 11/10/2022 Implemented
SIN-00151077 Renewal 02/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)The physical exam for individual #1 was dated 9/26/18 and the previous one was dated 8/31/17.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments and documentation. The nursing manager will be responsible to assure that all individuals in the future have a physical exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system.This citation was resolved on 3/28/19 when an individual in residential had their physical completed within regulatory timeframes. 03/08/2019 Implemented
6400.141(c)(9)The last prostate exam for individual #1 was dated 12/28/17.The physical examination shall include: A prostate examination for men 40 years of age or older. Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments and documentation. The nursing manager will be responsible to assure that all individuals in the future have a prostate exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system. This citation was resolved on 3/26/19 when an individual in residential had their prostate exam completed within regulatory timeframes. 03/26/2019 Implemented
6400.163(c)The 3 month psychiatric medication review for individual #1 between 9/27/18 and 1/14/19, exceeded 90 days. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments/documentation. The nursing manager will be responsible to assure that all individuals in the future have a psychiatric exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system. This citation was resolved on 3/28/19 when an individual had their psychiatric exam completed within regulatory timeframes. 03/28/2019 Implemented
6400.181(e)(3)(iv)The assessment dated 6/19/18 for individual #1 did not record their needs with or without assistance.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others.Based on the licensing review of February 26-27, 2019, the Program Specialist Manager retrained All Program Specialists on 3/7/19 about the importance of ensuring that the Annual Assessment indicates what an individual can do with or without assistance. The Program Specialist Manager will be responsible to review and assure that all Annual Assessments are completed according to regulatory requirements. This citation was resolved on 4/8/19 when the Annual Assessment for an individual included information about personal needs with or without assistance. 04/08/2019 Implemented
SIN-00126498 Renewal 11/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen is located to an adjoining furnace room which has dirt covering all its surfaces.Clean and sanitary conditions shall be maintained in the home. This citation was resolved on 11/20/17 when the closet was professionally cleaned. On 11/16/17, the Program Supervisor responsible for the site, as well as all Assistant Directors were sent a memo on the importance of keeping clean and sanitary conditions at all sites. It is the responsibility of the Program Supervisor to assure that each household maintains clean and sanitary conditions on a weekly basis. A CLA Site Checklist is completed on a weekly basis by the site supervisor to assure that all surfaces are clean and in good repair. 11/20/2017 Implemented
6400.76(e)One dinning room chair has split fabric in its seat. In homes serving eight or fewer individuals, there shall be dining tables with seating for all individuals at the same time.This citation was resolved on 11/21/17 when a new cover was purchased for the chair. On 11/16/17, the Program Supervisors responsible for the site, as well as all Assistant Directors were sent a memo on the importance of keeping clean and sanitary conditions at all sites. It is the responsibility of the Program Supervisor to assure that each household is in good repair on a weekly basis. A CLA Site Checklist is completed on a weekly basis by the site supervisor to assure that all surfaces are clean and in good repair. When items are not clean, worn or broken, the Program Supervisor will take corrective action to assure compliance with the regulation. 11/21/2017 Implemented
SIN-00067768 Renewal 06/26/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)A light cover was missing off of the ceiling light fixture in Individual #1's bedroom.Floors, walls, ceilings and other surfaces shall be in good repair. The missing globe light cover was replaced on June 30, 2014. The Site Supervisor/Program Specialist will ensure that all floors, ceilings and other surfaces are in good repair by completing a monthly inspection of the building. In the event that surfaces are not in good repair that information will be communicated to the departmental facilities persons for repair. 06/30/2014 Implemented