Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234170 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)On 11/8/23, Individual #1's funds and financial ledger were not present. House Manager #1 stated during the inspection that they had taken Individual #1's funds and financial ledger to their home "to keep them safe".The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. House manager immediately had the funds secured and an accounting verified. A lock box has been purchased to keep all funds and accounting records of financial transactions at individual #1 home. 01/31/2024 Implemented
SIN-00215605 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. CEO and program specialist to review applicable regulations for compliance. 03/01/2023 Implemented
6400.15(c)Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. 03/01/2023 Implemented
6400.76(a)The toilet seat in the first-floor bathroom was loosely secured and able to move over an inch from side to side. Furniture and equipment shall be nonhazardous, clean and sturdy. Toilet seat was unable to be safely secured and new toilet seat purchased and installed on 1/3/23. House manager will conduct monthly check of all furniture and equipment in the home to ensure it is non-hazardous, clean and sturdy. CEO will develop checklist for all house managers to maintain compliance. CEO and program specialist will verify monthly checklists are completed by house managers. 03/01/2023 Implemented
SIN-00197909 Renewal 12/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills conducted on 9/30/2021, 10/29/2021, and 11/3/2021 do not document whether any problems were encountered. The written fire drill records for the fire drills conducted on 9/30/2021 and 2/26/2021 do not document the exact time the fire drill was conducted.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. CEO will conduct a staff review/training on the regulatory requirements of 6400.112(c) and additional regulations in regard to fire safety and fire drills. House managers will be responsible for monthly review of fire drill records/documentation to ensure compliance with applicable regulations. 01/21/2022 Implemented
6400.112(e)A fire drill was not held during sleeping hours during the period from 1/1/2021 to 12/20/2021.A fire drill shall be held during sleeping hours at least every 6 months. Sleeping drill will be conducted immediately and will then be held at least every six months in the future in order to maintain compliance. Fire safety/drill training will be held with all staff to review applicable requirements and regulations. 01/21/2022 Implemented
SIN-00182301 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 had a gynecological examination on 4/11/19 and then again on 6/26/20.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. In order to prevent future violation and to ensure compliance, Program Specialist and CEO will monitor 6400.141(a)-(d) regarding Individual Physical Examinations on a monthly basis effective immediately. Documentation of monthly reviews will be kept. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely scheduling and completion of medical appointments including gynecological examinations. (DPOC by AES,HSLS on 2/16/21)] 02/10/2021 Implemented
6400.142(a)Individual #1 had a dental examination on 4/10/19 and then again 7/14/20.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Effective immediately, Program Specialist will conduct monthly reviews of Dental care as specified in 6400.142(a)-(h) to ensure compliance and prevent future violations. Documentation of the monthly reviews will be kept and monitored by CEO. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely scheduling and completion of medical appointments including dental examinations. (DPOC by AES,HSLS on 2/16/21)] 02/10/2021 Implemented
6400.181(a)Individual #1 had an assessment completed on 3/25/19 and then again on 9/9/20. 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. Program Specialist will review 6400.181(a)-(f) regarding Assessments to ensure compliance and prevent future violations. Additionally, Program Specialist and CEO will conduct monthly reviews of each Assessment. Documentation of this review will be kept. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure accurate, up-to-date and timely completion of individual's assessments. (DPOC by AES,HSLS on 2/16/21)] 02/10/2021 Implemented
6400.182(c)Individual #1's assessment, completed 9/9/20 indicates that Individual #1 needs full assistance to identify, use, and safely be around poisonous materials. Individual #1's ISP, last updated 1/21/21 reads, "[Individual #1] understands precautions for handling and storage of poisonous materials. She also recognizes warning labels and danger signs."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program Specialist will communicate with the plan team (specifically the Supports Coordinator) regarding the assessment and update to the individual plan. The plan team will work together to ensure the individual plan is developed based upon the most current assessment and then when updated annually or revised as individual needs change. [Immediately, the CEO or designee shall develop and implement a tracking system and auditing process to ensure accurate, up-to-date and timely completion of individual's assessments. (DPOC by AES,HSLS on 2/16/21)] 03/10/2021 Implemented