Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225887 Renewal 06/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no self-assessment fully completed three to six months prior to the license expiration or six to nine months after the last annual inspection.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. All C-NTA staff responsible for the self assessments will be trained on the proper time frames for completion of self assessments. 08/07/2023 Implemented
SIN-00189833 Renewal 07/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature tested at the kitchen sink was 133.8 degrees Fahrenheit at the time of inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water heater temperature was turned down and now reading 117 degrees F. During the inspection process it was noted that the thermometers used by each home were not adequate for measuring water temperatures. The agency has purchased new thermometers for every home. In addition, the agency has implemented b-weekly water temperature checks in each home which will be performed by the house manager. 07/19/2021 Implemented
6400.34(a)Individual #1 was not informed of the right to a locking mechanism for the home, which is covered under regulation 32s.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The agency has updated the Individual Rights Policy and reviewed this with Individual #1. Individual #1 was already exercising his right to have keypad access to his home. 07/22/2021 Implemented
6400.166(a)(11)Individual #1's Medication Administration Record does not include the diagnosis or purpose for their medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The agency has requested changes to the E-MAR system with the pharmacy that includes the ability to make changes to the MAR to add the diagnosis to each medication. In addition, new medications cannot be approved without the diagnosis being completed in the E-MAR system. 07/19/2021 Implemented
SIN-00242827 Renewal 04/30/2024 Compliant - Finalized