Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210783 Renewal 08/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 8/31/22 at 11:50AM, the hot water temperature at the bathtub in the bathroom on the second floor measured 123.7°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature was lowered immediately during inspection. 08/31/2022 Implemented
6400.46(b)Direct Service Worker #1 completed fire safety training on 2/26/21 then again 6/15/22.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The direct support worker has received his training for this year. We will make sure that he has his next training by 6/15/23. 09/07/2022 Implemented
SIN-00194374 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill conducted during sleeping hours occurred on 3/21/21.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill was conducted on 09/30/2021. Fire safety training was also provided to House Manager for reinforcement. A copy of the fire drill will be emailed separately. 09/30/2021 Implemented
6400.166(a)(11)The September 2021 Medication Administration Record for individual #1 did not include the diagnosis or purpose for the following medications: Therema-M Tab, Lactulose Solution 10 gm/15, Propranolol Tab 20 mg, and Clonazepam Tab 2mg.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.Medication diagnosis and purpose was written on the MAR. 10/11/2021 Implemented
SIN-00179077 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1 date of admission 12/2/19 had an initial assessment completed on 2/8/20. 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. On October 26, 2020 the Program Specialist created an "Assessment" document. On-Site Companionship Services will utilize this document when meeting with all SCO'S and SC's before the transition of the client takes place. This will ensure that all of the clients that On-Site Companionship Services cares for will either already have an assessment of receives their assessment within 60 days of transition. A copy of the document can be uploaded here or mailed in to the address that has been provided. [Immediately and upon hire, the CEO or designee shall educate the Program Specialist on the requirements and time frames of completing assessments 6400.181a-f. Documentation of the training shall be kept. Upon competition of assessments by the program specialist for at least one year, the CEO shall audit the assessment to ensure full, accurate and timely competition. Documentation of the training shall be kept. (DPOC by AES,HSLS on 12/8/20)] 10/26/2020 Implemented
SIN-00157303 Renewal 06/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.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. On June 17, 2019, Quinn Williams obtained a copy of the self-assessment of the home. On-Site Companionship Services shall complete a self-assessment of each home the agency operates, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance.Quinn Williams, Jaide Williams and Program Specialist will complete the assessment on the first day of the third month prior to the expiration date of the agency's certificate of compliance. [Upon completion and prior to 3 months of the expiration of the Certificate of Compliance, the CEO or designee shall audit the self-assessment documentation to ensure the most current self-assessment document is used and completed in its entirety. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 7/30/19)] 06/17/2019 Implemented
6400.81(k)(6)The bedroom at the top of the stairs does not contain a mirror.In bedrooms, each individual shall have the following: A mirror. On July 1, 2019, CCO, obtained a mirror and installed it in the bedroom. All other sites were inspected to ensure that a mirror was installed in the bedrooms. On the first day of every month, CCO, will travel to each site to inspect the bedrooms ensuring that a drawer and mirrors are installed. [Within 30 days of receipt of plan of correction, the CEO or designee will educate the CCO on the requirements of individuals' bedroom as per 6400.81(a)-(m) and any other physical site checks that COO is to check while on site. Documentation of the on site checks shall be kept. (DPOC by AES, HSLS on 7/30/19)] 07/01/2019 Implemented
SIN-00147900 Initial review 12/12/2018 Compliant - Finalized