| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was an approximately a 4x4 inch patch to the Left of (Individual # 1's ) Bedroom door trim that needs repaired and painted. Inside the box, the color is yellow, and the hallway is white, and there are two screw sized nail holes inside the box. | Floors, walls, ceilings and other surfaces shall be in good repair. | Item 4 SLC 0021
6400 - 67(a) Surfaces Floors walls ceilings and other surfaces shall be in good repair.
A section of the wall in the hallway beside CFs bedroom doorframe was a different color from the rest of the wall, and had two screw holes.
Correction made 3/9/2020 (photo evidence attached) .
Action to prevent recurrence- licensing tool is completed monthly for each service location.
Incorporated in the licensing tool is regulation 67(a).
Audit to ensure compliance:
The completed licensing tool for each home will be submitted to the operations manager monthly.
The Operations Manager will verify that all items noted are corrected and that the correction date is documented per 6400 15 ( c) |
03/09/2020
| Implemented |
| 6400.68(b) | The water temperature was 122.3 degrees, which is over the 120 degrees water temp regulation with the 2-degree variance. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Item 5 SLC 0021
6400 68(b) Running water. Hot water temperatures in bathtubs and showers may not exceed 120 degrees Fahrenheit.
The running water temperature of the bathtub was 122.3 degrees Fahrenheit.
Action to correct: Temperature setting for hot water will be reduced 2 degrees.
Action to prevent: House managers will be retrained on how to measure the hot water temperature of running water. Training sign in log attached.
Monitor to ensure compliance: Licensing tool will be completed monthly for each home.
Incorporated in the licensing tool is regulation 68(b). |
03/12/2020
| Implemented |
| 6400.216(a) | The top drawer of the filing cabinet, in the staff office, which houses the individual's files, was left unlocked and the office door was left unlocked and open at the time of inspection. | An individual's records shall be kept locked when unattended.
| Item 6 6400 216 (a) Access
An individuals records shall be kept locked when unattended.
Citation: the cabinet where the individuals records are kept was not locked and was unattended.
Action to correct: Cabinet was locked on 3/5/2020. Affidavit signed off by house manager
Action to prevent recurrence: Action to prevent recurrence- licensing tool is completed monthly for each service location.
Incorporated in the licensing tool is regulation 216(a).
Monitoring to ensure compliance:
The completed licensing tool for each home will be submitted to the operations manager monthly. |
03/09/2020
| Implemented |