| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Blue cleaning chemical liquid was found in an unlabeled spray bottle in a closet. | Poisonous materials shall be stored in their original, labeled containers. | This citation was resolved immediately on 11/10/22, while licensors were still on site, the Site Supervisor removed the unmarked bottle of cleaning solution from the cabinet. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of keeping poisonous materials properly secured and kept in their original labeled containers. Residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations and ensuring that cleaning material are in their original, labeled containers. |
11/10/2022
| Implemented |
| 6400.62(d) | Cases of bottled water were found stored in a closet alongside cleaning products such as Tide detergent, OxiClean, Lysol wipes, and Dawn dish soap. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | This citation was resolved immediately on 11/10/22, while licensors were still on site, the Site Supervisor removed and separated the water from the cleaning supplies. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of keeping poisonous materials separated from food. Additionally, residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations and ensuring that cleaning material are kept separate from food and water. |
11/10/2022
| Implemented |
| 6400.72(c) | The back door deadbolt was not operative; it could not lock. The lock was repaired during the inspection. | Outside doors shall have operable locks. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors, about the importance of ensuring that all doors are operable and in good repair. |
11/10/2022
| Implemented |
| 6400.82(f) | The bathroom did not have a trash can. | 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. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that each bathroom have a trash can and all regulatory items. |
11/10/2022
| Implemented |
| 6400.32(r) | Individual 1's bedroom door cannot be locked; the door does not have a locking mechanism. | An individual has the right to lock the individual's bedroom door. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors, about the importance of ensuring that individuals have the ability to lock their door. |
11/10/2022
| Implemented |
| 6400.46(b) | Staff Member 1 has not had a fire safety training in over a year. Their last training was dated 10/26/21. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | During the aftermath of COVID and ongoing high staff vacancy rates we continue striving to ensure that staff receive key areas of health and safety training. Based on the licensing review of November 9-10, 2022, the CLA Director conferenced with the Director of Training responsible for providing and tracking this important training emphasizing this as health and safety item that must be completed per regulatory requirements. Additionally, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the completion of the training, as well as the Assistant Directors about the importance of ensuring that staff are trained annually in Fire Safety |
11/16/2022
| Implemented |
| 6400.52(a)(1) | Staff Member 1 did not complete 24 hours of training during the 2021/2022 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Based on the licensing review of November 9-10, 2022, the CLA Director conferenced with the Director of Training responsible for providing and tracking the 24 hours of training, emphasizing this as health and safety item that must be completed per regulatory requirements. Additionally, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the completion of the training, as well as the Assistant Directors about the importance of ensuring that staff maintain their 24 hours of training per regulatory requirement. |
06/30/2022
| Implemented |