Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231423 Renewal 10/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At the time of the inspection, the exterior paint on the windows was chipping and peeling. Screens, windows and doors shall be in good repair. A maintenance request was placed with the landlord to repair the chipping and peeling paint on the exterior windows. A follow-up email was sent requesting a date of completion. Maintenance will come out to the home the week of November 6 to give an estimate as to when the work will be completed. CEO will reach out to licensing by 11/13/23 to provide the date of completion. 10/23/2023 Implemented
6400.151(c)(3)Staff #2's 12/11/21 physical does not state that they are free from communicable diseases, only "Free of TB, see immunization record". The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. CEO will fax Staff #2's physical form to the doctor's office on 11/3/23 and ask them to complete the missing section and return it to the provider by 11/13/23. 10/30/2023 Implemented
6400.181(f)Individual #1's Annual Assessment was sent to the ISP team on 04/04/23, not at least 30 days prior to the Individual Support Plan (ISP) meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Individual #1's annul assessment was sent, but was a few days late based on the ISP date. The Program Specialist will complete and submit all subsequent assessments 45-60 days prior to the date ISP meeting is to be scheduled. The Program Specialist will use a calendar reminder to alert them that the assessment needs sent. 10/26/2023 Implemented
SIN-00215413 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The annual furnace cleaning was completed on 3/17/21 not again until 11/21/22.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. The furnace has been cleaned and will be scheduled to be cleaned again before 11/21/2023 11/21/2022 Implemented
SIN-00199944 Renewal 02/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The 10/01/21 Self Assessment was not complete, only the physical site regulations were reviewed.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. 15a The Program specialist will complete a separate LII for each home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. This was a misinterpretation of the regulation, and won't be an issue moving forward. 02/14/2022 Implemented
6400.113(a)Individual #2 did not receive annual fire safety training timely; training conducted on 7/06/20 and not again until 9/02/21. An individual, including an individual 17 years of age or younger, shall be instructed 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. 113a Fire safety training will be completed annually. During the current inspection year the annual training date was changed to align with the rest of the company to simplify tracking, and a miscalculation occurred. This will not be an issue moving forward, and fire safety training for staff and individuals will be held annually and on-time moving forward. 02/14/2022 Implemented
SIN-00182956 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The 1/7/2021 Annual Physical does not include Information Pertinent to Diagnoses and Treatment in Case of Emergency; this section of the form is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Residential Program Specialist (PS) will update all parts of the physical allowed before sending to the doctors. When the physical returns to the program the PS will review all aspects of the physical, and recommendation, and will address any issues accordingly. Attached is the request and approval from the Dr office to update the information pertinent to diagnoses and treatment in case of Emergency. 02/20/2021 Implemented
6400.34(a)The Department issued updated rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 2/9/21 annual inspection, individual #1 was never informed of the individual rights as described in 6400.32.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.It is the Program Specialists (PS) responsibility to ensure that all induvial are informed of their rights and the process to report a rights violation. The PS will review yearly, or sooner if regulations change before the year with the individuals. A signed copy will be kept in their permanent files, and a copy given to each individual. Attached is the updated Rights form that was reviewed and signed with the individual. 02/11/2021 Implemented
SIN-00168015 Renewal 02/13/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnaces- The oil furnace was not cleaned annually. Individual #1 moved into the home 9/19/19. The home furnace has not been inspected or cleaned since 4/16/18.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. The furnace has been cleaned, it was cleaned on 2/17/2020, to ensure that it is not missed in the future the Administrative Assistant will monitor all inceptions and cleanings and will schedule future appointments. The next apportionment has been scheduled for 2/16/2021. Attached is the cleaning from the furnace on 2/17/2020. 02/17/2020 Implemented
6400.141(a)Physical exam- yearly- Individual #1 DOA was 9/19/19, the physical was not completed prior to admission. The physical was completed on 10/2019.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. It is the program specialist responsibility to ensure that all physicals are filled out and completed prior to admission and yearly after. This is to include all fields are filled out, and dated and signed, including the TB tests. The administrative assistant will review all physicals to ensure that they are complete and filled out on agency forms, and meet the deadline and criteria required. Attached is another individuals physical and admission date. 02/20/2020 Implemented
6400.141(c)(6)Physical exam- Mantoux TB was completed late 1/22/18 and not again until 2/6/20 for Individual #1.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. It is the program specialist responsibility to ensure that all physicals are filled out and completed prior to admission and yearly after. This is to include all fields are filled out, and dated and signed, including the TB tests every two years. The administrative assistant will review all physicals to ensure that they are complete and filled out on agency forms, and meet the deadline and criteria required.If there is a cancellation or change in a scheduled appointment, documentation will be added to the file. Attached is another individuals physical and admission date. 02/20/2020 Implemented
6400.181(a)Initial assessment- Individual #1's initial assessment was not completed within the 60 days of admission (9/19/19) The assessment was completed in December 2019. 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. The program specialist is responsible for completing all assessments with in the allotted time frame. The residential CEO is responsible for review all assessments/ reports to ensure they are complete, accurate and completed, reviewed and signed on the required time frame. Attached is a completed assessment that was completed within the 60 days of admission. 02/20/2020 Implemented
6400.181(d)Assessment- Individual #1's initial assessment was not signed and dated by the program specialist staff person #1.The program specialist shall sign and date the assessment. It is the residential CEO responsibility to check all assessments/report written by the program specialist to ensure accuracy and that all requirement are filled out, signed and completed. Another assessment is attached. 03/20/2020 Implemented
6400.32(r)Rights- Bedroom doors locked- Individual #1's bedroom door does not contain a locking mechanism for privacy.An individual has the right to lock the individual's bedroom door.The CEO and the House supervisor has spoken to each individual residing int the home. Due the the ability for some to use any form of locking system with their disabilities and also a concern from the individuals of the doors being locked, it is at each individual request that the doors remain as they are with no change to the locking system. This has been discussed with each individuals team and will be updated to reflect their wishes in each individual¿s ISP. 02/18/2020 Implemented