Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.51 | The back and side exists to the building were unsafe and inaccessible due to there being no landing or walkway. The back door exited out to an uneven surface of woodchips. The side door had unleveled blocks of cement. | A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs. | Maintenance staff will arrange for a contractor to create concrete walkways around the back and side exits. |
06/18/2018
| Implemented |
2380.61 | The phone systems in the building were unable to be tested as there were no phones in the building. | The facility shall have an operable, non coin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | The IT Coordinator will install two telephones that connect directly to an outside line in the building on 6/19/2018. ESP Solutions, a telephone vendor, will install the remainder of the phones on 6/25/2018. |
06/19/2018
| Implemented |
2380.62 | There were no emergency numbers listed in the building. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line. | The IMQA Coordinator will create laminated calling cards that will be posted on/by each telephone. |
06/19/2018
| Implemented |
2380.69(f) | In the men's bathroom there was a window in one of the stalls with no window covering. | Privacy shall be provided for all toilets by partitions, doors or curtains. | Maintenance staff will apply a frost coating to the men's bathroom window to ensure privacy. |
06/18/2018
| Implemented |
2380.83(b) | There were no emergency evacuation procedures posted in the building. | An evacuation diagram shall be posted in all areas of the facility. | The IMQA Coordinator will create evacuation diagrams that will be posted in each room and by each exit. |
06/19/2018
| Implemented |
2380.84 | There was not a fire safety inspection completed for the building. | The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | Maintenance will schedule a fire safety inspection with the deputy fire marshal before the program move date. |
07/03/2018
| Implemented |
2380.85 | There were various paints, a total of 7 containers stored next to the heating and hot water units. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. | The paint containers will be removed and stored in a safe location. |
06/13/2018
| Implemented |
2380.87(c) | During inspection staff were unable to operate the fire alarm system. | If the fire alarm is inoperative, arrangements for repair shall be made within 24 hours and the repairs completed within 4 working days of the time the fire alarm was found to be inoperative. | Maintenance staff will post laminated instructions on how to run a fire alarm test by the panel. Training on how to operate the panel will be incorporated into on site training for all staff. |
06/15/2018
| Implemented |