Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00163640 Renewal 10/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.64The handrail leading from the back dock was not secured at the bottom of the stairway. The rail looked to have rusted through and was not attached.Stairways, outside steps, porches and ramps shall have well secured handrails.Work order submitted on 10/4/19 and completed on 10/22/19. Safety Committee members were retrained on this regulation. Physical site inspection form is being revised to include a reminder to check handrails. Form will be revised and distributed for use by 11/30/19. In addition, the Associate Director will perform unannounced inspections at least once per quarter for the next 12 months. Implemented
2390.72(a)In the space designated by the staff who was present during inspection, as the old clean room, there were pallets of materials blocking anyone from clear passage through the room and to the exit.Passageways and work aisles shall be unobstructed at all times.Items being stored in this area were relocated away from the aisles and passageways (attachment 3). The building manager was retrained on this regulation. Safety Committee members were also retrained on this regulation and reminded to note any obstructed aisles on the physical site inspection form as well as ensure that any blocked aisle or passageway be unblocked immediately upon discovery. Additionally, the Associate Director will perform unannounced inspections at least once per quarter for the next 12 months. 10/29/2019 Implemented
2390.85(a)-1The Alarm Test Record for Plant #3 Located at 245 Andrews Road, dated 09/12/19 was held past 90 calendar days.A fire drill shall be held at least every 90 calendar days. This area of non-compliance was identified on the day of the fire drill, which was the 91st day after the previous fire drill. Director of Habilitation immediately retrained Program Specialists on this regulation and a corrective action plan was implemented (please see attachment 1). The attached documentation was reviewed by licensing staff during the inspection. 09/12/2019 Implemented
SIN-00139197 Renewal 07/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.56The water temperature was checked during inspection and did not go above 80 degrees.A facility shall have hot and cold running water that is suitable for drinking purposes, in bathrooms and kitchen areas.Work order submitted on 7/31/18, system checked on 8/1/18 and everything was in working order. The issue could not be duplicated. All faucets were checked on 8/1, 8/3, and 8/9; there was hot water at all faucets during each check. The Associate Director checked the faucets several more times during the remainder of August and throughout September. Again, there were no issues noted. Water temperature checks were added to monthly building checklist (attachment #2). Safety committee representative will ensure water checks are completed with monthly building inspection. (Note: Director of Habilitation participated in the August Safety Committee meeting and requested that ¿hot water checks¿ be added to the building inspection form. The Safety Committee chair was absent for this meeting so the Secretary noted the request, but deferred any further action until the Chair was present. On September 12 the Committee voted on the motion to revise the form; the motion carried and the form was revised on October 5. There is no completed form yet to include for documentation, so the blank form is being submitted. See attachment #8.) While the issue could not be duplicated, we have decided to replace our current water heaters with a high capacity, ¿on demand¿ system to ensure that there are no future issues. The third and final estimate for this process should be received in October and the new system should be installed by mid-November. Engineering Department is obtaining estimates and will schedule/oversee installation of new system. Director of Habilitation will monitor progress monthly until completion. 10/05/2018 Implemented
2390.59There were no emergency numbers listed.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneThere are no land-line phones in this building. Emergency numbers have been posted at various locations throughout the building¬ (attachment #4). Associate Director will monitor to ensure numbers are still posted during completion of quarterly fire drills. Staff have been retrained regarding this regulation and oriented to the location of each posting (attachment #5). 08/02/2018 Implemented
2390.83(a)The strobe light at exit #8 was inoperable.There shall be an operable fire alarm that is audible throughout the facility.Work order submitted 7/31/18, strobe light and bell replaced on 9/21/18 (attachment #9). At the fire alarm test on 9/27, the strobe light was once again not working. Alarm company returned on 9/28, discovered a faulty wire and replaced it. Fire alarm test completed on 10/4. Strobe and bell were operational (attachment #3). Bells and strobes will continue to be monitored during routine alarm checks and fire drills. Associate Director will bear primary responsibility for monitoring during these times. Staff have also been trained to monitor the strobes and bells during alarm tests and fire drills, and to report any issues immediately (attachment #5). 09/28/2018 Implemented
SIN-00051028 Renewal 10/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(a)There was no first aid area designated specifically to provide first aid.(a) A facility shall have a first aid area that is separate from the work area.Provider is creating a separate first aid area that is used exclusively for first aid. 12/20/2013 Implemented
2390.151(e)(12)The assessment for individual # 1 dated 9/1/13 did not recommend specific areas of vocational training. (e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.Assessments will include specific areas of vocational training and a competitive job when community employment is recommended. 12/20/2013 Implemented
2390.156(a)Individual # 1 quarterly ISP reviews of 1/1/13, 4/1/13, 7/1/13, and 10/1/13 did not comment on the progress and quality of the work.(a) 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Program Specialists will comment on the progress and quality of the work during the previous 3-month ISP review. 12/20/0213 Implemented
SIN-00115549 Renewal 06/01/2017 Compliant - Finalized
SIN-00064405 Renewal 10/21/2014 Compliant - Finalized
SIN-00038637 Renewal 07/25/2012 Compliant - Finalized