Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214379 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The fire drill held on 4/18/2022 was designated as a sleep drill. The drill was held at 10:46 PM which is not in compliance with sleep hours. A sleep drill should be held between the hours of 11:00 PM and 7:00 AM.A fire drill shall be held during sleeping hours at least every 6 months. The sleep time fire drills will be held at least every 6 months between the hours of 11:00pm and 7:00am. The Program Specialist Supervisors will schedule the time on the fire drill between the designated hours for each sleep time fire drill. 12/13/2022 Implemented
SIN-00197053 Renewal 12/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The carpeting on both the second and fourth steps leading to the upstairs had approximately 2-inch tears in them. This poses a tripping hazard. Surfaces shall be free of hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.The tears on the stairs were repaired immediately. The new product to replace the entire stairway carpeting will be installed when it arrives on December 28th. All other flooring/surfaces in other homes were checked to see if they are in good repair. When surfaces are not free of hazards, the maintenance department will be made aware. 12/03/2021 Implemented
6400.144During the monitoring Individual #1's pro re nata (PRN) medication Lotrimin Cream was not at the site.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The PRN Medication was made available immediately. All medications were compared to the MARs to be sure they were available. Upon receiving medications from the pharmacy they will be checked for accuracy. 12/07/2021 Implemented
6400.166(a)(11)The December Medication Administration Record (MAR) for Individual #1's pro re nata (PRN) medication Lotrimin Cream did not include the diagnosis or purpose for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The MAR was corrected immediately to include the diagnosis or purpose for the medication. All other MARs were reviewed to ensure they included the necessary information and were accurate. All Medication entries will be reviewed to ensure they contain all information. 12/02/2021 Implemented
SIN-00160757 Renewal 08/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected on 4/27/2017. It wasn't inspected again until 11/8/2018, which exceeds the annual requirement.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 furnace will be inspected within the fifteen day grace period of 11/8/19. All documentation of furnace inspections will be maintained by the maintenance department. All other furnaces have been checked to ensure they are in compliance. The Residential Supervisor will email to remind the maintenance supervisor to have the furnaces inspected annually, prior to the date of the last furnace inspection. 08/20/2019 Implemented
SIN-00101747 Renewal 10/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Well water testing was done on 11/17/2015, 2/9/2016, 5/19/2016, and 8/11/2016. The time period between 2/9/2016 and 5/19/2016 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.An internal schedule has been developed to be sure that the testing is done within the three month requirement. Program Supervisors will send reminder to Administrative Assistant. Administrative Assistant will contact the laboratory to tell them to pick up the sample and the homes to draw the sample. All samples will be done within the time limit. 10/25/2016 Implemented
SIN-00122606 Renewal 09/26/2017 Compliant - Finalized