| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(a) | At the time of the inspection, behind the men's toilets there was a large section where the paint was peeling off the wall. In the women's restroom, there was rust on the metal that holds the ceiling tiles together on the ceiling. There were also 5 ceiling tiles with water stains that need replaced. In the main program area near the back of the room there was a broken ceiling tile. | Floors, walls, ceilings and other surfaces shall be in good repair. | The sections of the men's restroom with peeling paint have been repainted (Attachments #1-3). The metal that holds the ceiling tiles together in the women's restroom has been replaced (Attachments #4-6). The identified ceiling tiles with stains/cracks have been replaced (Attachment #7). |
03/28/2024
| Implemented |
| 2380.58(b) | When opening the side exit door, there was a large rust colored piece of metal- approx. 24 inches round covering the sub pump. This piece of metal was not flush to the ground. This could be a tripping hazard when exiting or entering these doors. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The sump pump cover was fixed so that it is now flush to the ground. Additionally, an industrial mat was purchased and placed over the drainage area outside the side exit door to cover the sump pump cover (Attachment #8). |
03/28/2024
| Implemented |
| 2380.61 | During the walk-through the corded telephone and the cordless phone in the facility did not work. The screen indicated no line. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | On 03/27/2024 Comcast installed a phone line, wifi, and a fax line at the day program site (Attachment #9). |
03/28/2024
| Implemented |
| 2380.63(b) | At the time of the walkthrough, the side exit door had 2 broken panes of glass. | Screens, windows and doors shall be in good repair. | The bottom most broken pane of glass was replaced (Attachment #11), and the upper most broken pane of glass was covered on both sides with thick tempered glass, and sealed with an all season waterproof caulking glue. The crack in the glass was also sealed with the glue prior to installing the tempered glass (Attachment #12). Both panes of glass that were fixed can be seen in Attachment #10. |
03/28/2024
| Implemented |