Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228618 Renewal 07/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window in Individual 5 bedroom was not able to open and needs repair. Screens, windows and doors shall be in good repair. Royal Home Care maintenance contractor immediately opened the window and made it accessible on 08/01/23 to ensure compliance (see attached). 08/01/2023 Implemented
SIN-00208326 Renewal 07/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)There was no mirror in the basement bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Royal Home Care maintenance contractor immediately bought and installed a mirror in the bathroom (see the attached) on 7/22/2022. 07/22/2022 Implemented
6400.111(c)There was no fire extinguisher in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Fire extinguishers were immediately placed at designated places (see the attached). 07/22/2022 Implemented
6400.163(b)Individual 1's 8PM medications for 7/21/22 had been removed from their blister packs ahead of their administration and were found stored in a sandwich bag. The two that remained in their blister packs were Quetiapine and Sodium Bicarbonate.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.The staff responsible for removing the medications from the blister pack and placed them in a sandwich bag was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff in question was retrained along with existing and newly hire staff of 8/18/22 on medication administration foundation, procedure, and documentation by the agency¿s med trainer (see the attached). 08/18/2022 Implemented
6400.163(d)Individual #1's PRN clonazepam, a controlled substance, was not kept behind two locks; it was in a locked closet, but the box it was stored it was not locked.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.An additional lock was immediately purchased by the administrator to keep the control substance locked in the storage (see the attached). 07/22/2022 Implemented
6400.166(a)(13)None of Individual #1's 8AM medications had been signed for in their MAR on 7/21/22. Pills missing from their blister packs indicate they have been administered.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The staff responsible for the documentation error and removing medications from the blister pack was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff in question was retrained along with existing and newly hire staff on 8/18/22 on medication administration foundation, procedure, and documentation by the agency¿s med trainer (see the attached). 08/18/2022 Implemented
SIN-00190683 Renewal 07/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The agency failed to have the furnaces completed annually by a professional furnace company, no documentation of inspection and cleaning was kept.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. Maintenance contractor immediately completed the furnace inspection (see attached) on 07/27/21 to ensure compliance. 08/02/2021 Implemented
6400.151(c)(2)Tuberculin skin test was completed on 2/13/2020 and was not read until 3/15.2020 for employee #1 Based on the time of the reading the results are invalid and should have been repeated. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Per agency pre-employment procedure, physical exam should include Tuberculin skin test which must be read and dated accordingly. Going forward physical examination will be completed including the date of tuberculin skin test in the result. 08/02/2021 Implemented
SIN-00170101 Renewal 01/31/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The hall light on the second floor was not functioning at the time of the physical site review.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance contactor replaced bulb on second floor hall light on 01/31/2020. Going forward, the residential director will carry out a monthly physical check to ensure that lights are in proper operating condition. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 01/31/2020 Implemented
6400.71The telephone emergency numbers were not located near the telephone located in the vacant bedroom on the second floor.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. A list of emergency telephone number was posted in the second floor by the telephone on 01/31/2020. The residential director will periodically monitor that it is present by the telephone. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 01/31/2020 Implemented