| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | THERE WAS A BOTTLE THAT WAS LABELED WINDEX BUT WAS IDENTIFIED AS A DIFFERENT YELLOW SUBSTANCE BY STAFF WAS LOCATED IN THE CLEANING CLOSET. | Poisonous materials shall be stored in their original, labeled containers. | A shift checklist will be used by DSPs on every shift will be developed, and training done for all DSPs. The checklist will cover storage and handling of poisonous materials. This checklist will be completed by 3/31/18 |
03/31/2018
| Implemented |
| 6400.64(a) | THE DOOR JAMS THROUGHOUT THE HOME WERE COVERED WITH A BLACK SUBSTANCE CONSISTENT WITH DIRT. | Clean and sanitary conditions shall be maintained in the home. | After cleaning the door jams ¿Maintenance request was submitted on December 19, 2017 to paint around the doors and entrance. (see attachment #4)
The Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to checked, how often and who will complete the task. The checklist will be completed by 3/31/18. |
12/19/2017
| Implemented |
| 6400.67(a) | THE DOOR IN INDIVIDUAL #1'S BEDROOM HAD A HOLE ON THE BACKSIDE OF THE DOOR. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance request was submitted 12/19/17 and has been repaired (see attachment: #1). The Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to checked, how often and who will complete the task. The checklist will be completed by 3/31/18. |
12/19/2017
| Implemented |
| 6400.67(b) | THE LINT TRAP IN THE LAUNDRY DRYER WAS FULL WHICH PRESENTS A FIRE HAZARD. ALSO THERE WAS A BLACK SUBSTANCE THAT WAS CONSISTENT WITH MOLD ON THE WINDOW, WALLS AND SHOWER FLOOR IN THE BATHROOM. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 1. The lint trap in dryer was cleaned (see attachment #2). A maintenance request was submitted on 1/17/18 to remove the mold on the window, walls and shower floor in the bathroom (see attachment- #3)
2. The Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to checked, how often and who will complete the task. The checklist will be completed by 3/31/18. |
01/17/2018
| Implemented |
| 6400.112(c) | THE FIRE DRILL RECORD FOR 02/18/2017 DID NOT LIST THE EVACUATION TIME FOR THE DRILL. | 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. | New user friendly fire drill report form as well as a new fire drill review form will be developed in order to ensure all fire drill related regulations are met. Staff and Program Specialists will be trained when the forms have been approved. |
03/31/2018
| Implemented |