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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The bathroom's skylight was inoperative; it could not be opened, leaving the bathroom without ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| 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 skylights are operable for proper ventilation. |
12/02/2022
| Implemented |
| 6400.67(a) | The front door's handle was not operative. The door could not latch shut when closed and could easily be pushed open with minimal force. The deadbolt had to be turned to secure the door. The doorknob was removed and its repair begun during the inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | 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 and surfaces, are in good repair. |
11/10/2022
| Implemented |
| 6400.81(k)(6) | Individual 1's bedroom does not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | 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 every individual's bedroom has a mirror as well as other regulatory items. |
11/10/2022
| Implemented |
| 6400.111(c) | The kitchen did not have a fire extinguisher. The nearest extinguisher was hanging on a bracket nearby, but outside, the kitchen, on a wall in the dining room/office area. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Based upon previous inspections, The fire extinguisher was mounted on the adjoining kitchen wall, within arm's reach for ease of access. Nevertheless, 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 fire extinguishers are mounted inside the kitchen. |
11/10/2022
| Implemented |
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