Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202294 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was no window or mechanical ventilation in the bathroom, the skylight was not operational.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to proper ventilation to ensure all areas of the home has proper venting. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair and working conditions. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to proper ventilation to ensure all areas of the home has proper venting, to assure safety and to avoid accidents. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to proper ventilation. . When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes to proper ventilation to ensure all areas of the home has proper venting. 07/01/2022 Implemented
6400.112(e)A sleeping fire drill was not held every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 06/01/2022 06/01/2022 Implemented
SIN-00184595 Renewal 03/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no operative light outside the steps.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper lighting. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents, by 04/01/2021. 04/01/2021 Implemented
6400.67(a)The blinds located in the kitchen were not in good repairFloors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to blinds to ensure good repair. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to blinds. The owner will purchase blinds have them installed to ensure the home is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes blinds in the homes are presented in good repair. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the blinds being in good repair. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to blinds being in good repair. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair, by 04/01/2021 04/01/2021 Implemented
6400.111(a)There was no operable fire extinguisher located on the second floor of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Plan to fix the immediate problem: Compliance Manager will make sure all persons are aware of fire safety protocol and make sure extinguishers are on every level of the home. New staff and Residents instructs in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will place created form in the intake packet to ensure all new participants are will ensure, they are aware of fire safety protocol and make sure extinguishers are on every level of the home. New staff and Residents instructs in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home What will be corrected: will ensure, they are aware of fire safety protocol and make sure extinguishers are on every level of the home and was completed on 03/09/2021 When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will place created form in the intake packet to ensure all new participants are will ensure, they are aware of fire safety protocol and make sure extinguishers are on every level of the home. New staff and Residents instructs in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. - House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Compliance manager will ensure, they are aware of fire safety protocol and make sure extinguishers are on every level of the home, by 03/09/2021 03/09/2021 Implemented
6400.112(e)Between the dates of January 2020 and February 2021 there was only one sleep drill held on 2/6/2020.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 05/01/2021 05/01/2021 Implemented
SIN-00156860 Renewal 06/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light outside the backdoor had broken bulbs.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper lighting. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. -C.E. O will oversee that Compliance Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/08/2019 Implemented
6400.72(a)Individual #1's bedroom did not have a screen window. Individual #2's bedroom did not have a screen window.Windows, including windows in doors, shall be securely screened when windows or doors are open. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to especially when it comes to windows having screens. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. -C.E. O will oversee that Compliance Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to windows having screens. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/08/2019 Implemented
6400.141(a)Individual #1's annual physical dated 4/23/19 did not have all the required contents, including the following items; immunizations, hearing screening, vision screening, communicable disease precautions, assessment of health maintenance, physical limitations, info pertinent to diagnosis and diet instructions.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Plan to fix the immediate problem: Compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items; immunizations, hearing screening, vision screening, communicable disease precautions, assessment of health maintenance, physical limitations, info pertinent to diagnosis and diet instructions, in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items; immunizations, hearing screening, vision screening, communicable disease precautions, assessment of health maintenance, physical limitations, info pertinent to diagnosis and diet instructions, in accordance to the 6400 regulations. original signature only and not electronically sign individual physical form in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided. What will be corrected: That all participants primary care physical properly fill out annual physical forms. When and How: Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms. - primary doctor did not complete all areas of the annual physical form. - Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms. , by 08/01/2019. -C.E. O will oversee Compliance Manager¿s practices via a monthly meeting to review individual¿s records. Meetings will be started 08/01/2019 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Compliance manager monthly and review all Individual record to ensure all individual¿s files and to ensure all individual¿s primary doctors are properly filling out physical form, accordance to the 6400 regulation. 08/01/2019 Implemented
SIN-00131533 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The light in the basement was inoperable.Clean and sanitary conditions shall be maintained in the home. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.67(a)The surface of the kitchen oven exhaust fan had paint peeling from the surface.Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.67(a)The light switch on the kitchen wall was found to have rust on it.Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
SIN-00113352 Renewal 04/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The bathroom light fixture was missing 2 bulbs.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to light fixture and missing bulbs. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to light fixture and missing bulbs, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to light fixture and missing bulbs. Meetings will continue monthly and we will meet before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.68(b)The hot water temperature in the 2nd floor bathtub was 123.4° Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn't exceed 120°F, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn't exceed 120° F. Meetings will be continued and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.101Individual #2's bedroom and the spare bedroom had key locks.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. This problem was taking care of the 04/11/2017 Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: Some bedrooms and basement doors had useable key locks When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately, by 04/11/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done, to ensure items such as mirrors are on all individuals walls in their rooms. Meetings will continue on a monthly basis and we will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/11/2017 Implemented
6400.112(d)The fire drill on 8/19/16 had an evacuation time of 5 minutes. 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. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. The Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all fire drills are completed and evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. Meetings will continue and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.112(e)There was no sleep fire drill conducted between March 2016 to March 2017.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. In the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all sleep fire drills are done at least every six months or repeat of drill if exceeds that time period. Meetings will continue and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.144Individual #1 was administered the incorrect dose of Risperidone from 4/1/17 to 4/10/17. The dosage was decreased by the doctor from 1mg OD at 7pm to 0.5mg OD at 7pm, effective 4/1/17. The medication available to administer was 1mg. 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. Plan to fix the immediate problem: Staff will make sure all individuals have medication logs that match the labels after doctor visit. Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, while adhering to 6400 regulations. What will be corrected: Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit. Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit. - Medication logs had a medication that didn¿t match the labels after doctor visit. - Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, by 07/03/2017. -C.E. O will oversee Program specialist to make sure they are making sure the medication logs are matching the labels. C.E.O will continue to meetings will be continued and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program Specialist monthly and review all training to ensure all employees remain trained on individual service plans, focusing on an individual¿s medication logs a making sure the medication that matches the labels after doctor visit. 07/03/2017 Implemented
6400.181(a)Individual #1's last assessment was completed on 2/12/16. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Plan to fix the immediate problem: program specialist will create a form to be signed SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting but 365 days after last assessment was written as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. The Program specialist will create a form that will detail what is being given as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP but 365 days after last assessment was written. What will be corrected: program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting but 365 days after last assessment was written as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. When and How: Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a form that will be used to verify that the assessment is being given to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting but 365 days after last assessment was written, as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. -will create a for that keeps track of ISP due dates - Program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting but 365 days after last assessment was written, as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP, by 07/03/2017 07/03/2017 Implemented
6400.181(f)There was no documentation that individual #1's assessment dated 2/12/16 was sent to the supports coordinator. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Plan to fix the immediate problem: program specialist will create a form to be signed SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. The Program specialist will create a form that will detail what is being given as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. The program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. The Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a form that will be used to verify that the assessment is being given to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. -will create a form - Program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will continue and we will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
SIN-00076963 Renewal 04/08/2015 Compliant - Finalized