| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The bathroom vent is not mechanical, and the mechanism or tool used to operate its skylight was not available at time of inspection, and as such, the bathroom was not observed to be properly ventilated. The agency submitted a photograph showing that the tool used to open the skylight had been replaced after the conclusion of the site inspection. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| On the same day subsequent to the inspection, the facility manager provided documentation that the mechanical tool used to open the skylight was at the site. |
08/13/2021
| Implemented |
| 6400.66 | There was no light on the exterior door of the property's balcony at point of inspection. The agency submitted a photograph showing that a light was installed after the conclusion of the site inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The day following inspection. The facility manager had solar lights installed on the balcony of the property. |
08/14/2021
| Implemented |
| 6400.77(b) | The first aid kit did not have a thermometer at time of inspection. The agency submitted a photograph showing the thermometer was replaced after the conclusion of the site inspection. [Repeated Non-Compliance from 3/9/20] | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The person inspecting the site didn't realize there were two first aid kits. On the same day subsequent to the inspection, the COO submitted documentation that the thermometer was at the site. |
08/13/2021
| Not Implemented |