Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00195498 Renewal 11/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 1/12/21 and 9/24/21 did not address all regulations. The regulation pertaining to 141a (annual physical) was left blank.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. Who: Director of ID Services, Assistant Director of ID Services, Incident/Risk/Quality Manager What: ensure that the self-assessments are completed thoroughly with no section being left blank. When: During the regulated timeframe to complete the self-assessments How: 1. Retraining the ADOS and I/R/Q Manager were retrained and a discussion was held regarding the importance of ensuring that no sections on the self-assessment is left blank 2. New procedure-once the self-assessments are completed, the I/R/Q Manager will be responsible to complete a 2nd check to ensure that all sections have been completed. Attachments: B.1 letter signed by the ADOS and I/R/Q Manager verifying that they have been retrained and that they are both aware of the new procedure to provide additional oversight of the self-assessment before 11/24/2021 Implemented
SIN-00097651 Renewal 07/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The red, wooden, picnic table and plant stander had a lot of chipped and peeling paint. Floors, walls, ceilings and other surfaces shall be in good repair. Who: 1. All staff in Residential Program 2. Maintenance department if repairs are needed. 3. The Director of Services (DOS), Assistant Director of Services (ADOS) or ID Consultant to complete monthly monitoring. What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67. When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form. How: 1. Retraining for all staff in the Residential Program 2. Maintenance will be notified of need for repair and will complete repair. In the event that there is a concern where the maintenance department does not complete the work or does not complete the work as per regulations, the Executive Director will be notified by the DOS as per new protocol. 3. Updated the Administrative Regulation Monitoring Form 4. Furniture was disposed of at the county dump by ADOS. Attachments: ¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3) ¿ Completed Administrative Regulation Monitoring form that was updated to include patio furniture.(attachment # 5) 09/19/2016 Implemented
6400.103The written emergency evacuation procedure did not include staff and individual responsibilities. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Who: Assistant Director of ID Services What: Updated the form to include all regulatory requirements. When: After form was found to be out of compliance with regulations. How: Form was updated after licensing. All staff and individuals were trained in their responsibilities in the event that an evacuation must occur at one of the group homes. A copy of the form that was individualized for each individual, was placed in the individual¿s records at the home. Attachments: ¿ Copy of the Emergency Relocation Plan for each individual (attachment # 1) ¿ Signature showing that all staff and all individuals were trained in their responsibility (attachment # 2) 09/19/2016 Implemented
SIN-00229552 Renewal 09/05/2023 Compliant - Finalized
SIN-00178932 Renewal 11/09/2020 Compliant - Finalized
SIN-00160822 Renewal 10/01/2019 Compliant - Finalized
SIN-00117359 Renewal 08/21/2017 Compliant - Finalized
SIN-00063453 Renewal 03/05/2014 Compliant - Finalized
SIN-00069322 Renewal 03/05/2014 Compliant - Finalized
SIN-00045341 Renewal 02/21/2013 Compliant - Finalized