| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. | 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.
| A self assessment for the N. Everett Avenue home was started on 7/13/22 and ended on 7/14/22, signed by Katie Goetz, Program Specialist. |
12/29/2022
| Implemented |
| 6400.64(a) | The air vent in the hallway next to the medication closet was covered in a significant amount of dust. | Clean and sanitary conditions shall be maintained in the home. | The air vent will be cleaned by 1/31/23. |
01/31/2023
| Implemented |
| 6400.111(a) | The attic of the home did not have an operable fire extinguisher with a minimum 2-A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher will be put in the attic by 1/31/23. |
01/31/2023
| Implemented |
| 6400.163(d) | The closet where medications are stored in the home was not locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All medications are stored in a closet that has a keyed lock but wasn't locked. The medication closet is now locked when not in use. |
12/09/2022
| Implemented |