Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219070 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Cleaning supplies were located in the same through-way area leading to the basement as food such as cereal.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.71Emergency phone numbers were not located near a telephone in an individuals master bedroomTelephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Staff and residents reminded of the importance of these numbers being on every phone. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 02/23/2023 Implemented
6400.111(c)There was no fire extinguisher located in the kitchen. The fire extinguisher was located in the kitchen pantry throughway. The Fire extinguisher was relocated back to the kitchen during inspection. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Monthly fire drills and equipment checks will continue to be made to ensure appropriate equipment is present. 03/16/2023 Implemented
SIN-00199989 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Windshield washer fluid, cascade and soda bottles were stored together on the floor in the entryway foyer leading to the basement stairwell.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.All food items removed from area. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 02/01/2022 Implemented
SIN-00183896 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Medication, clobetasol ointment .05% PRN not present in home for individual #1.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Clobetasol ointment now in cart. 05/31/2021 Implemented
SIN-00156326 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)Individual #5's 3 month Individual Support Plan (ISP) Review dated 12/1/ 2018 TO 2/28/2019 was signed on 03/28/2019 which is a month after the ISP review.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All Care Coordination 6400 staff will be retrained by Directors and AVP on the importance of maintaining deadlines and time management skills. 6400 Program Planning Guidelines will be reviewed. Managing time will be a regular agenda item for department meetings. 07/31/2019 Implemented
SIN-00135816 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers posted by the telephone in the living.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Residential Manager posted a sign of local emergency numbers (attached picture). The Residential Manager will confirm the sign is by all phones during the environmental walk conducted monthly. 02/15/2018 Implemented
6400.112(a)In the month of October, the fire drill record did not indicate the exit route used, designated meeting place and the participant of the drill. An unannounced fire drill shall be held at least once a month. During the month of October, no residents where living at this home to conduct a fire drill. A test of the fire system was completed and the results indicated the system was fully operational (attachment #1). The Residential Manager will conduct monthly fire drills. These drills will also be reviewed and signed off by the Residential Director. 11/09/2017 Implemented