Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227045 Renewal 08/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The floor on the deck that wraps around the side and back of the home in not in good repair. There were multiple areas of the floor of the deck had peeling paint. The corner of the chain link fence at the edge of the driveway closest to the road is broken and is not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The maintenance director was asked to get the deck floor peeled and repainted as well as to get the small area of the chain link fence repaired. 08/31/2023 Implemented
6400.68(a)The home does not have hot running water under pressure. The temperature of water in the bathtub measured at 92.6 degrees.A home shall have hot and cold running water under pressure. The Maintenance Director adjusted the temperature of the water to 120-degree Fahrenheit. 08/30/2023 Implemented
6400.165(a)Medications in the home were not prescribed in writing by an authorized prescriber. There were five packets of antacid located in the first aid kit that were not prescribed to Individual #1.A prescription medication shall be prescribed in writing by an authorized prescriber.House Managers will check and remove all unwanted items from new first aid kits before dispatching them to the homes and each staff is responsible to check the first aid kits to ensure that only required items remained in the first aid kits. 08/30/2023 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 had reviews of these medications on 11/17/22 and 6/26/23. These reviews did not include the reason for prescribing the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Staff doing appointments will ensure that pertinent sections of the forms are completed correctly before leaving the appointment. 09/05/2023 Implemented
6400.166(b)Individual #1 is prescribed Geri-kot 8.6mg tablet, take one tablet by mouth twice a day. The 8PM signature blocks on the Medication Administration Record(MAR) for 8/22/23 through 8/29/23 appear to have had a line drawn through them and then erased and staff initials entered after being erased. The initials of the person administering the medications were not recorded at the time the medication was administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.A remediation was done with the staff member who inadvertently drew the line on the medication log and attempted to erase the line. All staff members were told to be cognizant of the medication logs and to avoid making any markings on the medication logs. 09/05/2023 Implemented
6400.207(4)(I)Individual #1 is prescribed Lorazepam 0.5mg, take ½ tablet by mouth every 6 hours as needed for anxiety. There is no written protocol available to address how and when this medication is to be administered.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The CEO will accompany individual #1 to the next medication review and request that the psychiatrist provides a written protocol for the medication in question. If the psychiatrist is reluctant to provide a protocol, then the CEO will look at other options such as requesting a discontinuation of the medication and prescribing a new medication to replace the discontinued medication. 08/31/2023 Implemented
SIN-00156812 Renewal 06/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home was completed on 5/24/19 which was not within 3 to 6 months prior to the Agency's license expiration date of 6/18/19.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. The Chief Executive Officer and the Maintenance Director will complete the self-assessment of each home twice a year to ensure that the self-assessment is completed in the time frame required by ODP. The self-assessment will be done annually in the months of December and March. 06/05/2019 Implemented
6400.107There was a portable electric space heater found in the laundry room.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The portable heater was removed and disposed of on 6/4/2019.The Maintenance Director was made aware of the findings and re-checked all homes to make sure that there was no presence of portable heaters. in addition, the Maintenance Director and all staff will ensure that any repair work done does not include the usage of portable heaters. Should the need arise that requires drying an area; fans, baseboard heaters and natural ventilation will be used. 06/06/2019 Implemented
SIN-00207748 Renewal 08/29/2022 Compliant - Finalized
SIN-00191833 Renewal 08/25/2021 Compliant - Finalized
SIN-00178383 Renewal 10/20/2020 Compliant - Finalized
SIN-00134413 Renewal 05/31/2018 Compliant - Finalized