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Milwaukee County Adult Family Home Provider Inspection Summary For DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Notes This report includes Provider Inspection Summaries (Facility Profiles) for Adult Family Homes in Milwaukee County. The report includes only facilities located within the City of MILWAUKEE. Reports for facilities located in other communities are listed separately on the DQA Facility Profile webpage. The report is a PDF (Adobe Acrobat) document and includes a total of 579.00 pages. If you wish to read the profile for a particular facility without scrolling through the rest of the document, use the Search feature in the Acrobat Reader to specify part of the name of the facility you wish to review. If you wish to print the profile for a particular facility, be sure to send only the desired pages to your computer printer. Otherwise you will be printing all pages in the document. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 1 HEAVENLY DIVINE ADULT FAMILY HOMES LLC (0015708) Address: 4637 N 24TH PL, MILWAUKEE, WI 53209 License Status: REGULAR Licensed/Certified/Registered 07/01/2015 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History Survey ID: 0133811 End Date: 04/01/2019 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT Results: STATEMENT OF DEFICIENCY ISSUED This is Page 2 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 1 STEP AWAY FROM HOME ASSISTED LIVING LLC II (0015825) Address: 2222 W BOLIVAR AVE UNIT 102, MILWAUKEE, WI 53221 License Status: REGULAR Licensed/Certified/Registered 10/06/2016 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History No survey activity during the period 8/24/18 to 8/23/21 This is Page 3 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 1 VILLARD STREET MANOR (0016620) Address: 5277 N 29TH STREET APARTMENT 1, MILWAUKEE, WI 53208 License Status: REGULAR Licensed/Certified/Registered 06/26/2017 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History Survey ID: 0137096 End Date: 06/07/2021 Type: OTHER Purpose: DESK REVIEW Results: ENFORCEMENT ACTION Statement of Deficiency: #P7ZU11 Served 08/26/2021 Compliance Deficiencies Cited Subject Area Verified Corrected 88.03(4)(b) RENEWAL REQUIREMENTS This is Page 4 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 5 STAR ADULT CARE SERVICES LLC (0016260) Address: 5442 N 20TH ST, MILWAUKEE, WI 53209 License Status: REGULAR Licensed/Certified/Registered 12/05/2016 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History Survey ID: 0137015 End Date: 03/02/2021 Type: STANDARD Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #FEWL12 Served 08/17/2021 Compliance Deficiencies Cited Subject Area Verified Corrected 88.04(5)(b) TRAINING-8 HOURS ANNUALLY 88.05(3)(e)2.b INSPECTIONS-GAS FURNACE 88.05(4)(d)2.b FIRE EVACUATION ANNUAL EVALUATION This is Page 5 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Survey ID: 0132038 End Date: 01/18/2019 Type: STANDARD Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #FEWL11 Compliance Deficiencies Cited Subject Area Verified Corrected 50.065(2)(b)intro ENTITY BACKGROUND CHECK 3/2/21 Yes REQUIREMENTS 88.05(2)(a) DIFFICULTY WALKING 3/2/21 Yes 88.05(3)(h)5 SPACE IN BEDROOMS 3/2/21 Yes 88.05(4)(d)2.a FIRE SAFETY EVACUATION PLAN REVIEW 3/2/21 Yes 88.05(4)(d)2.b FIRE EVACUATION ANNUAL EVALUATION 3/2/21 No 88.06(3)(d)1 DESCRIPTION OF SERVICES 3/2/21 Yes 88.07(3)(d) MEDICATION- WRITTEN ORDER 3/2/21 Yes Enforcement History (5 STAR ADULT CARE SERVICES LLC--0016260) Date: 08/17/2021 SOD #FEWL12 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION COMPLY WITH REQUIREMENT Date: 11/22/2019 SOD #FEWL11 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION COMPLY WITH REQUIREMENT Complaint History (5 STAR ADULT CARE SERVICES LLC--0016260) Date Complaint Received: 11/08/2018 Date Investigation Completed: 01/18/2019 Subject Area(s) Result SOD # PROGRAM SERVICES NOT SUBSTANTIATED This is Page 6 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 511 HOUSE ADULT FAMILY HOME LLC (0016293) Address: 511 N 34TH STREET, MILWAUKEE, WI 53208 License Status: REGULAR Licensed/Certified/Registered 06/21/2017 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History No survey activity during the period 8/24/18 to 8/23/21 This is Page 7 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Provider Inspection Summary STATE OF WISCONSIN Division of Quality Assurance Bureau of Assisted Living Printed 09/22/2021 For the period 08/24/2018 to 08/23/2021 P.O. Box 7940 Madison WI 53707-7940 Adult Family Home Facility Information Facility Name: 76TH STREET HOME (0011454) Address: 3380 S 76TH ST, MILWAUKEE, WI 53219 License Status: REGULAR Licensed/Certified/Registered 05/18/2006 12:00:00AM Regional Office: SOUTHEASTERN REGION (MILWAUKEE), (414) 227-2005 Survey History No survey activity during the period 8/24/18 to 8/23/21 This is Page 8 of 579 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete.
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