| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The master bathroom toilet (with the copper tub) needs to be cleaned; there is visible build up around the bowl at the water line. | Clean and sanitary conditions shall be maintained in the home. | Operations Director cleaned toliet. |
| Implemented |
| 6400.72(a) | In the individual's bedroom, there was no screen in the right window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The screen was missing. Director or Operations worked with LAndlord to order the scree. The screen was added. |
11/10/2023
| Implemented |
| 6400.110(e) | The home does not have an interconnected smoke detector system, which is required based on the home's floorplan. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The smoke alarms were hard wired but not interconnected. Director of Operations ordered, installed, and tested internconnnected alarms. |
11/10/2023
| Implemented |
| 6400.112(a) | There is no drill provided for February 2023 | An unannounced fire drill shall be held at least once a month. | The Director will re-train Operations Team on regulation 6400.112(a) as it pertains to the completion of monthly drills and record keeping. Training will also include a review of the Fire Drill Record form and the submission process. Operations staff will submit all completed fire drills on the Fire Drill Record form via paper. The Director will monitor to ensure they are completed and scanned into SharePoint (electronic record storage). |
10/10/2023
| Implemented |
| 6400.112(e) | There was only one sleep/overnight fire drill conducted during the tracking period of September 2022 to August 2023 (June | A fire drill shall be held during sleeping hours at least every 6 months. | The Director will re-train Operations Team on regulation 6400.112(a) as it pertains to the completion of monthly drills and record keeping. Training will also include a review of the Fire Drill Record form and the submission process. Operations staff will submit all completed fire drills on the Fire Drill Record form via paper. The Director will monitor to ensure they are completed and scanned into SharePoint (electronic record storage) Overnight drill was completed on 10/12023 |
11/03/2023
| Implemented |