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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | The closet contained an unlabeled spray bottle which contained a cleaning chemical. | 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. The residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations on the day regarding assuring that cleaning material are in their original, labeled containers, (11-10-22). |
11/10/2022
| Implemented |
| 6400.46(a) | Staff Member 1 has not yet received fire safety training, though they have begun working with individuals. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | During the aftermath of COVID and ongoing high staff vacancies 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 new staff are trained in fire safety before working with individuals. |
11/10/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment dated 7/21/16 was not completed 3 to 6 months prior to the expiration of the license dated 9/10/16. | 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.
| Based on the licensing review of November 29-30, 2016, on 12/1/16, the Assistant CLA Director responsible for the site, as well as all other CLA Assistant Directors were sent a memo from the CLA Director on the importance of assuring that the self assessment is completed within the regulatory timeframe. Additionally, the CLA Director has placed a reminder for the self assessment on all Assistant CLA Director's Outlook Calendars. It is the responsibility of all Assistant CLA Directors to assure that self assessments are completed for each site within regulatory timeframes. This will be reviewed annually by the CLA Director to assure compliance. |
12/01/2016
| Implemented |
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