Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00170286 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for fire drill that was held on 1/26/20 did not document the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. On 2/27/20, the Program Specialist contacted the House Supervisor who conducted the Fire Drill. House Supervisor, Kavel Thompson reported that the evacuation time should have been recorded as 1 minute and 17 seconds, she failed to carry over that time from the initial documentation. Program Specialist, Patricia Richardson reminded the House Supervisor as to the importance of filling out every piece of information on every document. Moving forward we will review the monthly Fire Drills at the time of our weekly Administrative Review Meetings to prevent recurrence of this incident. 02/27/2020 Implemented
SIN-00130811 Renewal 03/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The well water was tested on 10/19/2017. It wasn't tested again until 1/29/2018, which exceeds the 3 month requirement.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Water tests performed on January 29, 2018 were not conducted in a timely fashion due to winter weather conditions causing numerous power failures in our area. These power failures affected our electronic reminders including water testing. This was noticed when we checked our physical documentation on January 29, 2018 and noted that the electronic reminder was off. The tests were immediately carried out. Going forward in addition to the electronic reminder a hard copy calendar has been implemented. 03/06/2018 Implemented
SIN-00089390 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Water testing was performed on 1/20/2015. Water wasn't tested again until5/7/2015, which supassed the 3 month requirement. A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.The manual calendar has been modified. In addition, an electronic calendar has been created and will be maintained to identify tests and provide alerts prior to the test due dates to foster timely completion. The water test wll be completed and recorded by the Program Manager prior to the due date. The Deputy Director of Operations will check for compliance including results and date. 04/13/2016 Implemented
SIN-00071137 Renewal 02/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)Individual #3 did not have a review of her ISP every 3 months. The following reviews occurred for individual #3: annual on 3/4/2014, a Quarterly review on 9/3/2014, and 12/2/2014. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Wakefield Cottage's Program Specialist will complete an ISP review of service and the expected outcomes in the ISP for the individual every 3 months. The individual's next 3 month review was conducted on March 4, 2015 03/04/2015 Implemented
SIN-00218655 Renewal 03/28/2023 Compliant - Finalized
SIN-00201450 Renewal 04/14/2022 Compliant - Finalized