Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235630 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom does not have a window and the vent was not operable at the time of inspection.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Maintenance was made aware and replaced the vent on 12/22/23. The Site Supervisors and Program Manager were retrained on this regulation on 1/15/24. 12/22/2023 Implemented
6400.112(d)The fire drill recorded on 12/12/23 had an evacuation time of 2 minutes and 37 seconds. This time exceeds the 2 and half minute evacuation requirement. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The Site Supervisors and the Program Manager were retrained on fire drill requirements on 1/15/24. 01/15/2024 Implemented
SIN-00216002 Renewal 12/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguisher located in the attic of the home was not inspected annually. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All of the fire extinguishers at this home were exchanged before they expired except for the extinguisher in the attic. When the fire extinguishers were replaced in the home the one in the attic was missed. The Director of Operations replaced the expired extinguisher on 1/13/23. This home is currently vacant; therefore, does not have the level of oversight currently that our occupied homes have. 01/13/2023 Implemented
SIN-00197671 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete self assessments of the home for 2021.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. In response to the citation received in 2020, a self-assessment schedule was developed to track when assessments are to be completed for all programs. The Compliance Manager will review that schedule to ensure that the information is accurate and will make any needed corrections based on the current COC dates for all programs. The new schedule will then be used to track when all self ¿assessments are required to be completed. The Compliance Manager and Director of Operations will then develop an improved process/system that ensures the assessments are completed within the required timeframes. 02/28/2022 Implemented
6400.68(a)The home did not have hot running water during the time of inspection. This home is vacant. Licensing allowed the water to run for a significant amount of time and a temperature of 60 degrees Fahrenheit was recorded at the time of inspection.A home shall have hot and cold running water under pressure. The Office Manager has contacted a plumber to schedule for a consultation to have the water heater/ plumbing at the home checked to identify the problem. Once the problem is identified, any necessary repairs needed to correct and resolve the issue will be completed. . 02/28/2022 Implemented
SIN-00181616 Renewal 01/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was not a self assessment of the home completed 3-6 months prior to the expiration of the agency's certificate of compliance.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. : Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.15(a) by 3/12/21. Additionally, the Compliance Manager will develop a schedule to track when all self- assessments for Dayspring are to be completed. The current Certificate of Compliance for Dayspring 6400 programs is dated 9/23/20 - 9/23/21. The self- assessments for these programs will be completed between March 2021 and June 2021 to ensure compliance with this regulation. Director of Operations and the Compliance Manager will be responsible to ensure that the self- assessments are completed. The Compliance Manager will be responsible for continued monitoring to ensure ongoing compliance. 03/12/2021 Implemented