Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00188318 Renewal 05/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no outdoor lighting on site that would illuminate the area outside of the back door or the adjoining area in the rear of the property.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Correction ¿ Immediate Cure (Exhibit I and II) WHO: Residential Director Compliance Specialist Office Manager House Manager, upon hire Staff WHAT: We need to ensure that our homes have appropriate lighting outside so that each area is illuminated. HOW: We hired an electrician to place a light fixture for us outside the home. We also re-trained all the staff, Compliance Specialist, Office Manager and Residential Director on the 6400 regulations pertaining to physical sites, 6400.61 to 6400.86. The Office Manager, Residential Director and Compliance Specialist were re-trained on June 22, 2021. Staff were re-trained between June 17, 2021 and June 25, 2021. When we hire a House Manager, the House Manager will receive the same training. 07/30/2021 Implemented
6400.111(c)There was no fire extinguisher present in the site's kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Comment The fire extinguisher was located in the dining room, next to the kitchen. Correction ¿ Immediate Cure (Exhibit II and Exhibit III) WHO: Residential Director House Manager, upon hire Compliance Specialist Staff WHAT: We need to ensure that there is an overnight fire drill at lease once every six months. HOW: We place a fire extinguisher in the kitchen. We also re-trained all the staff, Compliance Specialist and Residential Director on the 6400 regulations pertaining to fire safety, 6400.101 to 6400.114. The Residential Director and Compliance Specialist were re-trained on June 22, 2021. Staff were re-trained between June 17, 2021 and June 25, 2021. When we hire a House Manager, the House Manager will receive the same training. 06/26/2021 Implemented
SIN-00174244 Unannounced Monitoring 07/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Dishwasher Detergent, a potentially poisonous cleaner was discovered under the sink unlocked during inspection. It was placed back in the locked closet by agency at the time of the inspection to ensure safety.Poisonous materials shall be kept locked or made inaccessible to individuals. WHO: Executive Director CFO/Residential Director House Manager Staff WHAT: We need to ensure that the dishwashing detergent is not accessible to the Consumer. HOW: The dishwashing detergent was removed entirely from the house. They only use liquid soap now, which the Consumer is aware that she should not digest. We re-trained the Residential Director and trained the House Manager to specifically look for presence of potentially poisonous items that are not locked up. The training occurred on July 21, 2020. In addition, we held training on Recognizing and Responding to potential causes/areas of abuse. The training was conducted by the Executive Director. During this training, the Executive Director informed employees of the citations. The group worked through the proper protocol to use when there is a potentially dangerous item in the home. The training occurred on August 4, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection - the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. The Executive Director will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity - Prevention of Reoccurrence We highlighted the portion about locking up potentially poisonous items on the weekly checklist, but we also included exposed potentially poisonous items as a form of abuse. In addition, the Residential Director and the House Manager now split the homes during weekly inspection to ensure that they pay more attention to each home. 08/04/2020 Implemented
6400.64(a)A substance consistent with dirt and grease was discovered under the microwave, above the stove top in the kitchen at the time of inspection.Clean and sanitary conditions shall be maintained in the home. WHO: Executive Director CFO/Residential Director House Manager Staff WHAT: We need to ensure that the microwave is completely cleaned, including the outside/under portion of the microwave. HOW: We cleaned the microwave both inside and outside. We re-trained the Residential Director and trained the House Manager to pay closer attention at appliances during the weekly site inspection. The training occurred on July 21, 2020. In addition, we held a fire safety training during which the Trainer pointed out the dangers of grease fire. The training was conducted by a state certified fire safety instructor. The training occurred on August 11, 2020 and August 12, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection - the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. The Executive Director will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity - Prevention of Reoccurrence The Residential Director and the House Manager now split the homes during weekly inspection to ensure that they pay more attention to each home. 08/12/2020 Implemented
6400.80(b)The top stair on the outdoor sidewalk leading to the entrance of the house was cracked and uneven. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.WHO: CFO/Residential Director House Manager WHAT: We need to ensure that the outside building is well maintained, in good repair and free of unsafe conditions. HOW: The stair was repaired. We re-trained the Residential Director and trained the House Manager to pay closer attention to the outside building during the weekly site inspection. The training occurred on July 21, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection - the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. Correction Activity - Prevention of Reoccurrence The Residential Director and the House Manager now split the homes during weekly inspection to ensure that they pay more attention to each home. 08/02/2020 Implemented
6400.82(f)There were no clean paper or cloth towels to dry hands in the second floor bathroom at the time of physical site inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. WHO: Executive Director CFO/Residential Director House Manager Staff WHAT: We need to ensure that all bathrooms have paper towel or cloth towel for drying hands. HOW: We placed paper towel in the upstairs bathroom. We re-trained the Residential Director and trained the House Manager to pay closer attention to needed household items during the weekly site inspection. The training occurred on July 21, 2020. In addition, we held training on recognizing and responding to potential causes/areas of abuse. The training was conducted by the Executive Director. During this training, the Executive Director informed employees of the citations. The group discussed the need to ensure that household items are replaced, as needed, since they have access to their assigned home's supply closet. The training occurred on August 4, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection - the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. Correction Activity - Prevention of Reoccurrence The Residential Director and the House Manager now split the homes during weekly inspection to ensure that they pay more attention to each home. 08/04/2020 Implemented
SIN-00172591 Unannounced Monitoring 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Potentially poisonous Drano Cleaner was left unlocked under the kitchen sink cabinet. All other cleaners were locked in the closet near the dining area.Poisonous materials shall be kept locked or made inaccessible to individuals. Correction - Immediate Cure WHO: Executive Director CFO/Residential Director HOW: 1. We moved the Drano to the locked closet near the dining area. 2. We created a daily flammable and poisonous substance checklist, which staff are required to complete on a daily basis. 3. We created a weekly checklist for the Residential Director, in which he specifies whether staff completed the flammable and poisonous substance checklist. 4. Staff re-training on Flammable substances- March 27, 2020 to April 3, 2020 5. We will continue to conduct the Weekly Site Inspection check, as indicated in our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. 6. Weekly Site Inspection - a weekly site inspection will be conducted by the Residential Manager. 7. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. 8. Weekly Site Inspection Checklist Training 9. Maintenance Hotline Training, Residential - During a weekly site inspection, residential director's required to call the maintenance hotline to report any maintenance related issues. The residential director was trained on the Maintenance Hotline on March 18, 2020. 10. Maintenance Hotline Training, Office- The Administrative Assistant, Esther Brinson, was re-trained on the Maintenance Hotline on March 17, 2020. 11. Weekly Site Inspection Audit - Executive Director, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity - Prevention of Reoccurrence We will now forward copies of the Manager's Flammable and Poisonous Checklist and work orders to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. 04/03/2020 Implemented
6400.67(b)Dryer Lint was found in the dryer lint trap in the basement and some lint was scattered throughout basement floor and nearby shelving. The excess lint was not properly disposed of. The basement floor was damp and the rug was soaked with water. It was unknown at the time of inspection the cause of the dampness. [REPEATED VIOLATION 11/22/19] Floors, walls, ceilings and other surfaces shall be free of hazards.Correction - Immediate Cure WHO: Executive Director CFO/Residential Director HOW: 1. We removed the dryer lint from the dryer lint trap in the basement. 2. Staff re-training- March 27, 2020 - Staff was re-trained on completing their daily tasks. A copy of the daily task was also forwarded to staff, and placed at each home. 3. We will continue to conduct the Weekly Site Inspection check, as stated in the POC submitted on or about December 9, 2019, to identify deficiencies that need to be fixed. 4. Weekly Site Inspection - a weekly site inspection will be conducted by the Residential Manager. 5. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. 6. Weekly Site Inspection Checklist Training 7. Maintenance Hotline Training, 8. Maintenance Hotline Training, Office- The Administrative Assistant, was re-trained on the Maintenance Hotline on March 17, 2020. 9. Weekly Site Inspection Audit - the CEO will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity - Prevention of Reoccurrence We will now forward copies of the Weekly Site Inspection document and work orders to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. 04/03/2020 Implemented
6400.71Emergency telephone numbers were not located on or nearby the telephone in the living area during monitoring. [REPEATED VIOLATION 11/22/19]Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Response The emergency numbers are actually on the wall in the dining room. However, the telephone is in the living room, on the other side of the wall. Correction - Immediate Cure WHO: Executive Director CFO/Residential Director Administrative Assistant WHAT: We need to ensure that the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are posted on or by each telephone in the home with an outside line. HOW: 1. We moved the emergency numbers to the wall near the telephone in the living room. 2. The original mirror on the back of the door. Therefore, we moved it to the wall so that it is immediately apparent that there is a mirror in the room. 3. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. 4. Weekly Site Inspection - the weekly site inspection will be conducted by the Residential Manager. 5. Weekly Site Inspection Frequency - All homes must be inspected at least once per week. 6. Weekly Site Inspection Checklist Training 7. Maintenance Hotline Training, Residential 8. Maintenance Hotline Training, Office - The Administrative Assistant was re-trained on the Maintenance Hotline on March 17, 2020. 9. Weekly Site Inspection Audit - Executive director, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity - Prevention of Reoccurrence We will now pictures of the emergency number posters to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. 04/03/2020 Implemented
SIN-00162744 Renewal 09/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a fish tank in the bedroom of individual #1, who is currently not living in the home. The tank was half full and had the appearance of a black substance consistent with mold throughout.Clean and sanitary conditions shall be maintained in the home. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager WHAT: We need to ensure that the fish tank is clean, thus ensuring clean and sanitary conditions are maintained in the home. HOW: 1. We cleaned the fish tank on September 20, 2019, and removed the fish tank with the Consumer¿s permission on November 21, 2019. 2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day. 5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019. 6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019. 7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019. 8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man. Correction Activity ¿ Prevention of Reoccurrence We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 12/26/2019 Implemented
6400.66The light by the back door of the home in the basement had a broken bulb left in the fixture. Staff was unable to remove the bulb to install a new one.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager WHAT: We need to ensure that there is sufficient lighting in the home, which includes rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes. This will involve changing the way in which we currently conduct our weekly home inspections. HOW: 1. We fixed the light fixture on September 20, 2019. 2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day. 5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019. 6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019. 7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019. 8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man. Correction Activity ¿ Prevention of Reoccurrence We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 12/26/2019 Implemented
6400.67(b)The dryer vent in the basement was disconnected from the wall and leaning against an interior wall. The hole left from the vent was open. There was a pile of clothing in back of the dryer consisting of approximately 8 items. Floors, walls, ceilings and other surfaces shall be free of hazards.Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager WHAT: We need to ensure that all floors, walls, ceilings and other surfaces are free of hazards. HOW: 1. We fixed the dryer on September 20, 2019. 2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day. 5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019. 6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019. 7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019. 8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man. Correction Activity ¿ Prevention of Reoccurrence We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 12/26/2019 Implemented
6400.104The notification letter to the fire department dated 2/4/19 did not include exact location of individuals bedrooms.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. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Rachael Cohen, Compliance Specialist WHAT: We need to ensure that the notification to the fire department contains information related to the exact location of each Individual¿s bedroom. WHEN: Fire Department Notification Policy ¿ September 23, 2019 Fire Department Notification Policy training for the Compliance Specialist ¿ September 25, 2019 Fire Department Notification Policy training for the Program Specialist ¿ September 25, 2019 New Notifications Sent to Fire Department ¿ September 20, 2019 to November 20, 2019 HOW: We drafted a Fire Department Notification Policy and conducted training on the policy. We also re-sent the letters to the fire department. Correction Activity ¿ Prevention of Reoccurrence The policy was initially part of the admission process and assigned to the Program Specialist. We created a separate Fire Department Notification policy and assigned the task to the Program Specialist and Compliance Specialist. In the policy, there are sample letters to send for notification. 11/20/2019 Implemented
6400.105There was a gas lawn mower stored in the basement of the house, and had gasoline in the mower.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager All Staff WHAT: We need to ensure to flammable and combustible supplies and equipment are utilized safely and stored away from heat sources. HOW: 1. We removed the lawn mower from the basement on September 20, 2019. 2. We drafted the flammable and Combustible Supplies policy on September 30, 2019. 3. Staff was trained on the Flammable and Combustible Supplies Policy on November 21 and 22, 2019, then again from December 23 to 25, 2019. 4. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 5. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 6. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day. 7. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019. 8. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019. 9. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019. 10. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man. Correction Activity ¿ Prevention of Reoccurrence We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 12/26/2019 Implemented
6400.112(c)The fire drill for September 2018 did not include if the smoke detector was operable, it was left blank.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. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager WHAT: We need to ensure that Fire Drill form is fully completed so that it indicates whether the smoke detector was operable at the time the fire drill was conducted. WHEN: Fire Drill Policy Updated¿ September 23, 2019 Fire Drill Policy training for Program Specialist ¿ September 24, 2019 Fire Drill Policy training for House Manager ¿ October 29, 2019 HOW: The Fire Drill Policy was updated, and a training was conducted for the Program Specialist and House Manager on September 24, 2019 and October 29, 2019. Correction Activity ¿ Prevention of Reoccurrence We changed the assignee for the task by updating the assignee section of the Fire Drill Policy. Rather than the task being completed by the staff, then reviewed by the House Manager, the task can only be completed by the House Manager, then reviewed by the Program Specialist. This will ensure that all the sections are completed during the fire drill. 10/29/2019 Implemented
6400.112(e)The time of day ( AM/PM) was not indicated on some of the fire drills, it could not be determined if sleep drills were held.A fire drill shall be held during sleeping hours at least every 6 months. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager WHAT: We need to ensure that there is a clear indication on the Fire Drill form of when the fire drill was conducted, so that we know whether we are in compliance with the requirement to have at least one fire drill during sleeping hours. WHEN: Fire Drill Form Updated ¿ September 23, 2019 Fire Drill Form training for Program Specialist ¿ September 24, 2019 Fire Drill Form training for House Manager ¿ October 29, 2019 HOW: The Fire Drill form was updated, and a training was conducted for the Program Specialist and House Manager on September 24, 2019 and October 29, 2019. Correction Activity ¿ Prevention of Reoccurrence We changed our Fire Drill form to have a mandatory option to check off for AM/PM instead of leaving the option of providing the information up to staff. We also changed the assignee for the task. Rather than the task being completed by the staff, then reviewed by the House Manager, the task can only be completed by the House Manager, then reviewed by the Program Specialist. 10/29/2019 Implemented
6400.141(c)(6)The last tuberculin test was completed on 4/24/17 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. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Iris West, Nurse Tanya Carter, House Manager WHAT: We need to ensure that each Individual has Tuberculin skin testing by Mantoux method with negative results every 2. WHEN: Updated Appointment Policy ¿ October 15, 2019 New TB testing for Individual 1 ¿ October 24, 2019 Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019 HOW: The Program Specialist took Individual 1 for TB testing on October 24, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy. Correction Activity ¿ Prevention of Reoccurrence We updated our appointment policy so that the appointment timeline is clearer. This ensures that appointments are timely. 10/29/2019 Implemented
6400.141(c)(11)Health maintenance needs were not addressed in the physical dated 5/2/19 for individual #1.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Iris West, Nurse Tanya Carter, House Manager WHAT: We need to ensure that each Individual¿s physical is fully completed so that there is a list of recommendations for health maintenance, medication regimen and the need for blood work at recommended intervals. WHEN: Updated Appointment Policy ¿ October 15, 2019 Physical Form review by Nurse ¿ October 21, 2019 Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019 Physical Form re-training for Program Specialist ¿ November 13, 2019 Physical Form training for House Manager ¿ November 13, 2019 New physical for Individual 1 ¿ November 20, 2019 HOW: The Nurse reviewed the physical form, then trained the Program Specialist and House Manager on the form. Individual 1 has an appointment for a new physical on November 20, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy. Correction Activity ¿ Prevention of Reoccurrence We updated our appointment policy so that staff can no longer attend annual appointments such as physicals alone. In the updated policy, a staff must be accompanied by the Nurse, Program Specialist or House Manager for physicals. This ensures that the physical form is reviewed for accuracy before the Individual leaves the doctor¿s office. 11/22/2019 Implemented
6400.141(c)(14)Information pertinent to diagnosis in case of emergency was left blank on the physical form dated 5/2/19 for individual #1.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Iris West, Nurse Tanya Carter, House Manager WHAT: We need to ensure that each Individual¿s physical is fully completed so that it indicates the medical information pertinent to diagnosis and treatment in case of an emergency. WHEN: Updated Appointment Policy ¿ October 15, 2019 Physical Form review by Nurse ¿ October 21, 2019 Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019 Physical Form re-training for Program Specialist ¿ November 13, 2019 Physical Form training for House Manager ¿ November 13, 2019 New physical for Individual 1 ¿ November 20, 2019 HOW: The Nurse reviewed the physical form, then trained the Program Specialist and House Manager on the form. Individual 1 is scheduled for another physical on November 20, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy. Correction Activity ¿ Prevention of Reoccurrence We updated our appointment policy so that staff can no longer attend annual appointments such as physicals alone. In the updated policy, a staff must be accompanied by the Nurse, Program Specialist or House Manager for physicals. This ensures that the physical form is reviewed for accuracy before the Individual leaves the doctor¿s office. 11/22/2019 Implemented
6400.144Individual #2's medication, Polyeth Powder was not available at the time of this inspection. Staff signed for the 8am dose. The inspection took place at 9:30.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. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager All Staff WHAT: We need to ensure that there is an adequate system for accurately accounting for each medication so that it is clear that the needed medical, nursing, pharmaceutical, dental, dietary and psychological services are arranged for and/or provided. WHEN: Medication Administration Policy/Checklist Updated ¿ September 23, 2019 Medication Administration Policy/Checklist training for Program Specialist¿ September 24, 2019 Medication Administration Policy/Checklist training for House Manager¿ October 29, 2019 Medication Administration Policy/Checklist training for Staff¿ November 21 and 22, 2019 HOW: We updated the Medication Administration Policy/Checklist, and trained the Program Specialist and House Manager on the new policy. Staff will be trained by November 22, 2019. Correction Activity ¿ Prevention of Reoccurrence We updated our Medication Administration Policy/Checklist to ensure that the mediation administration process is clearer. We posted the revised Medication Administration Policy/Checklist at each home, above the table on which the Medication Administration book is kept. We also put the Medication Administration Policy/Checklist inside the Medication Administration book. 11/22/2019 Implemented
SIN-00140990 Renewal 06/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water in the bathtub was tested and found to be 124.7 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Correction - Immediate Cure WHO: Elvira Berry, Executive Director Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that the water temperature does not exceed 120 degrees Fahrenheit. Therefore, we need to ensure that the water is regularly measured. WHEN: Water Temperature Reduction - June 20, 2018 Fire Drill document updated - June 22, 2018 Updated Fire Drill Procedure Training - June 25, 2018 Fire Drill conducted - July 7, 2018 HOW: The water temperature was turned down to below 120 degrees Fahrenheit. On June 22, 2018, we updated the Fire Drill Form to include questions related to the water temperature. Training was conducted on June 25, 2018. A fire drill was conducted on July 7, 2018 with the updated form. A copy of the fire drill updated fire drill was sent to ODP. Correction Activity - Prevention of Reoccurrence We will only use a Fire Drill Form that has the ODP recommended questionnaire. This will ensure that we test the water temperature on at least a monthly basis during the fire drill. The Fire Drill Form will now be sent to the Executive Office within 48 hours of being conducted. The Executive Office must review the Fire Drill Form for compliance within 24 hours of receipt. This new review process will ensure that the supervisory personnel are testing the water temperature at least once per month. 07/07/2018 Implemented
6400.81(k)(6)Individual #3 bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. Correction 1 Immediate Cure WHO: Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that each Individual has a mirror in her room. WHEN: Mirror installed - June 21, 2018 House Inspection Training - June 29, 2018 - Rachel Cohen House Inspection Training - July 28, 2018 - Shamaine Bennett HOW: We installed the mirror in Individual #3's room. We also re-trained the Compliance Specialist and the House Manager so that they are able to notice these non-compliance circumstances during their weekly house inspection. Correction Activity - Prevention of Reoccurrence The mirror was in the closet. A House Manager or Compliance Assistant could have prevented the citation by closing checking the regulations. In the past, we required either the House Manager or the Compliance Assistant to conduct a weekly house inspection. We now require the Executive Director, Compliance Assistant and House Manager to each conduct a weekly House Inspection. This means that there are three people checking the houses to ensure compliance on a weekly basis. 07/28/2018 Implemented
6400.110(e)The fire alarms in the home, which was three stories were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Correction - Immediate Cure WHO: Rachel Cohen, Compliance Assistant Shamaine Bennet, House Manager WHAT: We need to ensure that the smoke detector on all floors are interconnected so that smoke related dangers will be simultaneously detected. WHEN and Professional contacted to install interconnected smoke detector - June 19, 2018 Interconnected smoke detector installed - June 20, 2018 How: The new interconnected smoke detector was installed on June 20, 2018. Correction Activity - Prevention of Reoccurrence The problem is that the original interconnected smoke detector was installed by a staff. Therefore, we made the decision that the interconnected smoke detectors will only be installed by professionals. Thus, preventing incorrect installation. 06/20/2018 Implemented
6400.112(h)On 5/1/18 the fire drill record did not indicate the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Correction - Immediate Cure WHO: Elvira Berry, Executive Director Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that our residents and staff are able know the designated meeting place so that there are no confusions during an emergency. Fire drills are conducted by the supervisory personnel. Therefore, we need to ensure that the supervisory personnel have the training needed to fulfill their responsibilities. WHEN: Fire Expert Training - May 24, 2018 and June 6, 2018 Fire Drill document updated - June 22, 2018 Updated Fire Drill Procedure Training - June 25, 2018 Fire Drill conducted - July 7, 2018 HOW: We already had a fire safety training by a safety expert on June 15 and 23, 2017. On June 22, 2018, we updated our Fire Drill Form so that the designated meeting place is moved up to the first line on the form. A fire drill was conducted on July 7, 2018 with the updated form. A copy of the fire drill updated fire drill was sent to ODP. Correction Activity - Prevention of Reoccurrence On the old Fire Drill document, the designated meeting place blended in with the document, which caused the employees to miss the requested information. Therefore, we updated the form, and instituted a policy that the Fire Drill Form will only be printed on color. The different colors on the form will help employees with completing the form accurately. 07/07/2018 Implemented
SIN-00176319 Renewal 09/14/2020 Compliant - Finalized