Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202295 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Lint the size of a baseball was observed in the dryer, which could cause a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.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 clearing the dryer of lint. 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 especially when it comes to clearing the dryer of lint. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to all dresser knobs be present to ensure 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 clearing the dryer of lint. - 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 clearing the dryer of lint. 06/01/2022 Implemented
6400.104There is no documentation that the local fire department was notified that Individual 2 resides in this home. Individual 2 is visually impaired, so the pertinent information should have been provided to the fire department through an updated notification letter when the individual moved into the residence.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Plan to fix the immediate problem: Compliance Manager will make sure all persons are aware of fire safety protocol and fire department is notified of participants and their disabilities. 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 make sure all persons are aware of fire safety protocol and fire department is notified of participants and their disabilities. They 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 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: Compliance Manager will make sure all persons are aware of fire safety protocol and fire department is notified of participants and their disabilities by 06/01/2022 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 give an updated notices to the fire department. The Compliance Manager will make sure all persons are aware of fire safety protocol and fire department is notified of participants and their disabilities. 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. 06/21/2022 Implemented
6400.112(a)Unannounced fire drills were not held monthly. No fire drills were conducted for the month of 12/2021 or from the months of 04/2021 through 08/2021. An unannounced fire drill shall be held at least once a month. 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 at least monthly and do a drill if one wasn¿t completed. 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 evacuation is done within 2 ½ minutes monthly and didn¿t exceeds this time. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the evacuation monthly, drill was missed that month. 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 monthly. - 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, monthly. 06/01/2022 Implemented
6400.112(d)The Fire Drill conducted on 11/21/2021 exceeded the 2½ minutes. No written reason was provided, nor was there an extension from a Fire Safety Expert. The evacuation time was listed as 2 min and 46 sec. 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. 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 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 06/01/2022 06/01/2022 Implemented
6400.144Medication SIMVASTATIN 20mg for Individual 1 was signed by staff as administered on 03/19/2022, but the medication was present in the individual's med box. This medication was not administered as prescribed.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: Compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items; 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 individuals are getting proper health services. Especially when it comes to including the following items, 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 are getting proper health services. 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 individuals are getting proper health services. - Some Health services weren¿t identified at time of inspections. - 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 individuals are getting proper health services, by 06/01/2022. 06/01/2022 Implemented
SIN-00184596 Renewal 03/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling in individual #3's bedroom was stained and had a substance that exhibited mold like look.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 mold or water spots, to ensure that home is being in 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 the maintenance man make the repairs, 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 mold or water spots, to ensure that home is being 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 mold or water spots, to ensure that home is 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 mold or water spots, to ensure that home is 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 mold or water spots, to ensure good repair, by 04/01/2021 04/01/2021 Implemented
6400.110(a)The home did not have an operable automatic smoke detector, when staff attempted to set the detector off it only sounded a low short beep. Rendering the detector inoperable. A home shall have a minimum of one operable automatic smoke detector on 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 smoke detectors are working. 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. Owner also established and contract with FAMCO, to ensure all homes are up to code, and staff are trained biannually. This violation was corrected on 03/09/2021. 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 smoke detectors are working. 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. Owner also established and contract with FAMCO, to ensure all homes are up to code, and staff are trained biannually. What will be corrected: will ensure, they are aware of fire safety protocol and make sure smoke detectors are working 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 smoke detectors are working properly. 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. Owner also established and contract with FAMCO, to ensure all homes are up to code, and staff are trained biannually. - 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, smoke detectors are working properly, by 03/09/2021 03/09/2021 Implemented
6400.112(e)There was no sleep drill held between 3/16/2020 and 1/15/2021A 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-00156861 Renewal 06/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The two doors on the main level connecting to the hallway did not close. Screens, windows and doors shall be in good repair. 8. 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 doors on the main level connecting to the hallway not closing completely. 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 doors on the main level connecting to the hallway not closing completely. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to doors on the main level connecting to the hallway not closing completely 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 doors on the main level connecting to the hallway not closing completely. - 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 doors on the main level connecting to the hallway not closing completely. - 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 doors on the main level connecting to the hallway not closing completely. -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 doors on the main level connecting to the hallway not closing completely. 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
6400.77(b)The first aid kit provided upon inspection did not include scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Plan to fix the immediate problem: House Manager will walk through the sites and review all First aid kits to make sure all components are on site as listed in the 6400 regulations, such as the scissors. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the scissors . What will be corrected: House Manager will replace all first aid kits, at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the scissors. 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. House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Scissors . - House Manager will walk through the sites monthly to ensure all first aid kits , at all sites, are equipped with all components are on site as listed in the 6400 regulations, such as the scissors . - House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the scissors, by 06/06/2019 -C.E. O will oversee that House Manger via a monthly meeting to ensure walk throughs are being done and to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the scissors. Meetings will continue and will meet monthly before or around the 5th of the month, starting July of 2019. A plan to prevent future occurrence: C.E.O will continue to meet with House Manager monthly. 07/15/2019 Implemented
SIN-00132678 Unannounced Monitoring 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #3 was admitted to the agency on 1/2/18 with no record of an intake physical exam being completed. An exam completed on 8/2/17 was later received by the agency on 3/27/18. Individual #3 has a chronic illness and was not being seen by specialists for this condition.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: The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent. All financial records will be updated and correct. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. What will be corrected: The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, to ensure all financial records are remaining current and up to date. When and How: The C.E.O will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance : The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. - The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. - The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, to ensure all financial records are remaining current and up to date., by 04/20/2018 -C.E. O will be overseen by the owner via a monthly meeting to ensure create a record of monies received and spent on individuals completed and kept up to date and that The C.E.O examined all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented