| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The ceiling fan lightbulbs in individual's 5 bedroom not working and need to be replaced. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance replaced all light bulbs per regulations. |
05/24/2022
| Implemented |
| 6400.67(a) | The wall in individual's 5 bedroom sitting area needs a fresh coat of paint on the patched area. | Floors, walls, ceilings and other surfaces shall be in good repair. | Manitenance painted area. Individual 5 bedroom . |
05/24/2022
| Implemented |
| 6400.68(b) | Water temp in hall bathroom at tub 123.6 degrees | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Maintenance adjusted water heater to not excceed 120°F. |
05/24/2022
| Implemented |
| 6400.68(b) | Water temp at the sink in hall bathroom 122.3 degrees f | Hot water temperatures in bathtubs and showers may not exceed 120°F. | provider adjusted water heater |
05/24/2022
| Implemented |
| 6400.72(a) | No screen in either window in individual's 4 bedroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Maintenance repaced windows added screens (new) and confirmed security |
05/24/2022
| Implemented |
| 6400.72(a) | No screen in right window in individual 's 5 bedroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | screen installed by maintenance , Program manager will check to insure individual 5 bedroom windows and doors shall be securely screened when windows and doors are open, |
05/24/2022
| Implemented |
| 6400.72(b) | Crack in left window in individual's 4 bedroom needs to be replaced.
The Middle window is cracked in multiple places in individual's 5 bedroom- (work order requested) | Screens, windows and doors shall be in good repair. | Maintenance replaced windows in individual 5 bedroom . |
05/24/2022
| Implemented |
| 6400.76(a) | The cover for the ceiling light fixture in the kitchen was removed exposing wires, cover needs to be secured to the base. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Provider maintenance replaced the ceiling light fixture in thr kitchen was repaired and secure . |
05/24/2022
| Implemented |
| 6400.77(b) | There was No thermometer found in the first aid kit. | 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. | Program managers and ad will confirm that there is a therometer in all first aid kits at all times. |
05/24/2022
| Implemented |
| 6400.112(c) | The fire drill held on 09/11/2021 was not recorded completely as evacuation time, exit route, and if detectors was operative was omitted/left blank on the form. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Provider will continue monthly fire drills for compliance and regualtion. |
09/28/2022
| Implemented |