Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220423 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment, completed on 1/29/23, the agency certificate of compliance expires 8/27/2023.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. LIIs are scheduled to be completed beginning on the week of 3/20/23. Once completed, the LIIs will be turned into the Director of Compliance for review and to maintain. 05/27/2023 Implemented
6400.82(e)On 3/1/23, the bathtub in the bathroom located between the bedrooms was observed without having a non-slip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. A non-slip mat was placed in the bathtub on 3/15/23. (PHOTO) All Supervisors were instructed to confirm that non-slip mats are present at their sites no later than 3/24/23. . 03/15/2023 Implemented
6400.104The home's Local Fire Department Notification Letter did not include the exact location of the individual's bedroom.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. This individual is capable of independently evacuating. Thier letter was pulled. All supervisors were instructed to review the evacuation abilities of their individuals no later than 3/17/23. Supervisors were also asked to confirm that inaccurate or incomplete evaucation letters be updated using the provided template no later than 3/24/23. 03/20/2023 Implemented
SIN-00184013 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspection was completed on 9/27/19 and then again on 12/01/20.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director of Res spoke to the Maintenance Director regarding time frames for annual furnance inspections. A tentative date was scheduled for furnace inspections for 2021 in September. Furnance inspections will be added for discussion to the Health and Safety agenda for the September and October meetings as a reminder for upcoming inspections and subsequent review of completed inspections by the Health and Safety Committee.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/10/2021 Implemented
6400.112(f)The fire drills completed on 1/28/21 and 11/14/20 had the exit route documented as the garage. There is no man door in the garage. [repeat violation 10/22/19]Alternate exit routes shall be used during fire drills. All Site Supervisors were training on proper evacuation procedures on 3/1/21. Every quarter for the next year, fire drill logs will be reviewed by the AD of Residential for 10% of all sites. The AD will review that alternate exits were used, evacuation times, varying dates/times for fire drills and that only "man doors" were used during the fire drill. Documenation of the review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/01/2021 Implemented
6400.165(g)Individual #1 had a review of medications prescribed to treat symptoms of a psychiatric illness, completed 6/08/20 and then again 10/27/20, [repeat violation 10/22/19]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All residential individuals who have psychiatric medications reviewed by their PCP were identified. The Site Supervisors who have individuals with this arrangement were training on using the proper documentation for psychiatric medication review appointments, that includes sections regarding reasons for continuation of medications. The Res Director will review 90 day psych med review appointments for these individuals every quarter for the next year to confirm that the proper documentation was used and fuly completed.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/01/2021 Implemented
SIN-00145460 Renewal 11/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Direct Service Worker #1, date of hire 2/19/18, did not have orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Temp. records will be reviewed to ensure that all current temp employees have received required trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. 12/31/2018 Implemented
6400.46(f)Direct Service Worker #1, date of hire 2/19/18, did not have training in general fire safety. Direct Service Worker #2, date of hire 9/5/18, did not have training in general fire safety.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Temp. records will be reviewed to ensure that all current temp employees have received required annual trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. 12/31/2018 Implemented
6400.112(e)A fire drill was held during sleeping hours on 12/31/17 and then again on 7/24/18A fire drill shall be held during sleeping hours at least every 6 months. At the next Site Supervisor meeting on 1/9/19, all Supervisors will be trained to run an overnight fire drill quarterly. Site Supervisors will be trained to review the fire drill logs monthly to ensure that drills are being run properly. Quarterly, the Asst. Directors will audit the fire drill logs to ensure that an overnight drill was conducted. Documentation of audits will be maintained by the Asst. Directors. 01/09/2019 Implemented
SIN-00086537 Renewal 11/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature at the only bathtub of the home was 122.7 degrees Fahrenheit at 10:32 A.M. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperatures will be checked weekly in all sites.[The CEO or designee will immediately check all the water temperatures in all the homes, if any of the temperature are above 120 degrees Fahrenheit then water temperature will be taken at least daily until 120 degrees Fahrenheit or below for 7 days and then taken weekly as specified in aforementioned POC. All water temperatures will be recorded and maintained and reviewed by the CEO or designee at least quarterly. Within 30 days of receiving the Inspection Summary, the CEO or designee will develop procedures for staff who are taking water temperatures to follow for taking temperature and to follow if water temperatures exceed 120 degrees Fahrenheit. Staff will be educated on the procedures, documentation of education will be maintained. (AS 11/24/15)] 11/28/2015 Implemented
SIN-00054189 Renewal 09/23/2013 Compliant - Finalized