| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The individual's room was missing closet door and a dresser drawer. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Supervisor placed a request to maintenance for repair. Dresser drawer and closet door were fixed by maintenance on 3/12/26. |
03/12/2026
| Implemented |
| 6400.67(b) | The home's deck had loose wooden deck boards.
The ladder to the attic was wobbly, and the bottom third section of the folding ladder twisted.
The dryer in the home had excessive lint built up.
The window was broken in the staff/sensory room. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Supervisor placed a request to maintenance to reinforce some of the nails and add new ones to the deck area as well as fixt the broken window in the sensory room. The Director communicated with landlord to replace attic ladder and placed a request to maintenance to secure the ladder. The Supervisor removed the lint on 2/12/26. Estimated date for ALL maintenance repairs is 4/1/26. |
02/12/2026
| Implemented |
| 6400.81(j) | The individual's bedroom door was missing. | A bedroom shall have doors at all entrances for privacy. | The Supervisor placed a request to maintenace to have the bedroom doorway replaced. Maintenance measured the doorway and provided the estimated completion date of 3/16/2026. |
03/16/2026
| Implemented |
| 6400.81(k)(6) | The individual's room did not have a mirror | In bedrooms, each individual shall have the following: A mirror. | Mirror was replaced on 2/12/26 by the Supervisor. |
02/12/2026
| Implemented |
| 6400.104 | There was no documentation of notification to he local fire department for this location. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Documentation of the notification letter will be maintained in the fire safety binder within the home by the Supervisor. The letter was placed into the binder by the Supervisor on 2/13/26. |
02/13/2026
| Implemented |
| 6400.110(a) | The smoke alarm in the attic did not sound when activated. This was corrected with a replacement battery during the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Director replaced the battery on 2/12/26. |
03/12/2026
| Implemented |
| 6400.111(a) | The fire extinguisher in the attic was not the required minimum 2-A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Supervisor changed the extinguisher to a 2-A rating on 2/12/26. |
03/12/2026
| Implemented |