| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Water damage around window is causing large cracks in plaster/sheetrock around the window. The damage has caused loose debris at the bottom of the window frame | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The agency contractor was dispatched and repaired the wall around the window. |
12/09/2022
| Implemented |
| 6400.112(c) | The fire drills on 3/28/22, 4/23/22, 5/24/22 all drills took 2 minutes flat to exit the home. | 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. | 1. The Program Supervisor and Program Director are responsible to ensure that monthly fire drills occur and meet regulation. If a fire drill does not meet regulation a new drill is to occur. |
12/09/2022
| Implemented |
| 6400.163(a) | Hibiclense medication left in basement behind storage counter/bar area that was not labeled. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | 1. This was corrected at the time of inspection. The medication was removed from the home. |
12/09/2022
| Implemented |