| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.61 | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. At the time of the inspection, the urinal in the men's bathroom had an "out of order" sign on it. When the licensing representative asked the agency staff why the urinal was inoperable, they were unaware of the specific reasons as to why it was broken, but that it was not operable. The sink located in the men's bathroom had duct tape over a middle section of it, and the same sink had several areas of a red/rust like color in it. At the time of the inspection, there were approximately 2 containers placed in the facility to catch water that would drip from the ceiling. At the time of the inspection there was no water in the containers and water was not dripping from the ceiling. Agency staff reported that the ceiling didn't leak during the winter, but there has been drips recently. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | The urinal in the Mens restroom will be removed. The sink will be replaced, and the leaks will be repaired in order to remove the bins that were catching water from the program area. |
05/26/2023
| Implemented |
| 2390.62 | Sanitary conditions shall be maintained in bathrooms. The bathroom sink located in the men's room had what appeared to be a gray almost black film that coated the entire sink as well went behind the wall of the sink. | Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. | The sink was thoroughly cleaned, though some stains remain. The sink will be cleaned with a stronger cleanser to see if the stains can be removed. If this cannot be done, we will be replacing the sink. |
05/26/2023
| Implemented |
| 2390.71(a) | Bathrooms shall be ventilated by operable windows or mechanical ventilation. The men's bathroom had no ventilation at the time of inspection. There was no operable window or mechanical ventilation located in the men's bathroom. There was a cut out in the backwall, but it was not an operable window, and it did not open to the outside. | Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation. | The building owner was contacted regarding adding a vent fan in the mens' restroom. |
05/26/2023
| Implemented |
| 2390.83(b)-1 | An employee trained in the operation of the equipment shall check the fire alarm monthly. There was no documentation that a monthly fire alarm checked occurred in October 2022. | An employe trained in the operation of the equipment shall check the fire alarm monthly. | Fire safety checks are completed after fire drills are held. Fire drills were scheduled for the remainder of the calendar year, with reminders that will alert the staff to the required drill/inspection. |
04/28/2023
| Implemented |