Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00212252 Renewal 09/30/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)On 12/15/2021, the fire drill record did not record the time it took for individuals to evacuate the program.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 was operative.1. The fire drill form was improperly filled out as the time to exit was put in the place of the time the drill occurred on that specific date. The form will be corrected by 10/31/2022 with the appropriate information in the appropriate locations by the Assistant Site Manager. 2. The other fire drills for from 9/1/21 through October 2022¿s fire drill records will be reviewed and corrected as necessary by the Assistant Site Manager. 11/11/2022 Implemented
2380.111(c)(1)The physical dated 4/22/22 for individual 1 did not note whether medical history summary was not reviewed. The box was not checked as reviewed.The physical examination shall include: A review of previous medical history.1. The Assistant Site Manager will be sending individual 1's physical back to the family for completion by the doctor by 10/31/22. 2. A review will be completed for all physicals for individuals currently in attendance to ensure the medical history was reviewed by November 30, 2022. Those without appropriate medical history review will be sent back to families or caregivers for physicians to complete. 3. Assistant Site Manager will send out a letter to all families letting them know we are going to audit physicals and send back for completion by 10/31/2022. 12/01/2022 Implemented
2380.181(e)(13)(iv)The assessment dated 3/7/2022 did not adequately update the individual 1's progress over the last 365 calendar days and current level in in recreation socialization from the assessment dated 3/7/21.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.1. Individual 1's assessment for 2022 will be updated to include current level in recreation and socialization by 10/31/2022 by the Assistant Site Manager. 2. All individuals assessments will be reviewed and updated as necessary for current level in socialization and recreation by 11/30/2022 by the Assistant Site Manager. 12/01/2022 Implemented
2380.36(b)Fire safety training for staff 1 was not completed annually. On 11/23/2020 the staff was initially trained but was not retrained until 2/24/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).1. All staff training records will be audited to ensure they are currently in compliance with fire safety training regulations. Any staff members out of compliance will be trained at the earliest opportunity. This will be completed by 11/30/2022 by Peaceful Living's Training Coordinator. 12/31/2022 Implemented
SIN-00152379 Renewal 03/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)There was a bottle of Air Wick Room Deodorizer unlocked in the men's bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The daily chore charts for staff will be updated to include a visual inspection to ensure appropriate storage of any and all poisonous materials. In each room a reminder sheet will be posted to refresh staff of all cleaning and inspection responsibilities. Site staff will be trained on the appropriate regulations and expectations. This will be completed by Friday, May 17, 2019. 05/17/2019 Implemented
2380.181(a)Individual #1's record did not contain a current assessment. The last one completed was dated 7/24/17. Individual #2 had an assessment dated 10/24/18 but there was not an assessment for 2017.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Program specialists will complete an assessment for 2018 for Individual #1. Program specialists will provide a 2017 assessment for individual #2. Program specialists and Site Manager will be retrained on assessment regulations and expectations. This will be completed by Friday, May 17, 2019. 05/17/2019 Implemented
2380.181(d)Individual #2's current assessment dated 10/24/18 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment.Program specialists will sign and date the assessment from 10/24/2018. Program specialists and Site Manager will be retrained on assessment regulations and expectations. This will be completed by Friday, May 17, 2019. 05/17/2019 Implemented
2380.186(a)Individual #1's record did not contain any 90 day ISP reviews. Individual 2's record did not contain any 90 day ISP reviews.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.The program specialists will complete the missing 90 day reviews for individuals 1 and 2. Program specialists and Site Manager will be retrained on 90 day ISP review regulations and expectations. The program specialists will review and revise as necessary the tracking form that details due dates for clients¿ 90 day ISP reviews and assessment to make sure they are correct. A new procedure will be devised to provide additional oversight of paperwork completion in order to provide more supports as necessary. Expected completion by Friday, May 17, 2019. 05/17/2019 Implemented
SIN-00136464 Initial review 06/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.51The back and side exists to the building were unsafe and inaccessible due to there being no landing or walkway. The back door exited out to an uneven surface of woodchips. The side door had unleveled blocks of cement.A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.Maintenance staff will arrange for a contractor to create concrete walkways around the back and side exits. 06/18/2018 Implemented
2380.61The phone systems in the building were unable to be tested as there were no phones in the building.The facility shall have an operable, non coin-operated telephone with an outside line that is easily accessible to individuals and staff persons.The IT Coordinator will install two telephones that connect directly to an outside line in the building on 6/19/2018. ESP Solutions, a telephone vendor, will install the remainder of the phones on 6/25/2018. 06/19/2018 Implemented
2380.62There were no emergency numbers listed in the building.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.The IMQA Coordinator will create laminated calling cards that will be posted on/by each telephone. 06/19/2018 Implemented
2380.69(f)In the men's bathroom there was a window in one of the stalls with no window covering.Privacy shall be provided for all toilets by partitions, doors or curtains.Maintenance staff will apply a frost coating to the men's bathroom window to ensure privacy. 06/18/2018 Implemented
2380.83(b)There were no emergency evacuation procedures posted in the building.An evacuation diagram shall be posted in all areas of the facility.The IMQA Coordinator will create evacuation diagrams that will be posted in each room and by each exit. 06/19/2018 Implemented
2380.84There was not a fire safety inspection completed for the building.The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept.Maintenance will schedule a fire safety inspection with the deputy fire marshal before the program move date. 07/03/2018 Implemented
2380.85There were various paints, a total of 7 containers stored next to the heating and hot water units.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.The paint containers will be removed and stored in a safe location. 06/13/2018 Implemented
2380.87(c)During inspection staff were unable to operate the fire alarm system.If the fire alarm is inoperative, arrangements for repair shall be made within 24 hours and the repairs completed within 4 working days of the time the fire alarm was found to be inoperative.Maintenance staff will post laminated instructions on how to run a fire alarm test by the panel. Training on how to operate the panel will be incorporated into on site training for all staff. 06/15/2018 Implemented
SIN-00232190 Renewal 09/27/2023 Compliant - Finalized