| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agencies expiration date of their certificate of compliance is 3/4/25. The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/4/24 to 1/4/25, and the self- assessment was completed 1/30/25. This exceeds the requirement. Per the Regulatory Compliance Guide (RCG) there is no grace period for this regulation | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| This reg. is important to measure the record of compliance with the chapter
When the instructions about doing self-assessment between the date of the letter to the date of the inspection, only that assessment was presented to the inspector. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 |
03/10/2025
| Implemented |
| 6400.62(c) | Poisonous substances shall be stored in their original labeled container. A decorative container without a manufacturer's label was found under the kitchen containing a blue liquid that presumably was a type of hand soap. It was not possible to determine if the liquid was toxic or nontoxic since it was not in the original labeled container. Agency staff did throw the container out during the inspection. | Poisonous materials shall be stored in their original, labeled containers. | It is important that poisons are kept in original container with the original labels to avoid misused. At the time of the inspection, an empty decorative container without label was found with a blue liquid. The individual does paint, and she had her paint kept in the container for easy access. |
03/05/2025
| Implemented |
| 6400.73(b) | When exiting the home from the office of the home to the back porch/patio area there are 3 steps that lead to the back porch/patio area and the steps did not have a handrail. | Each porch that has over an 18-inch drop shall have a well-secured railing. | Handrail for stairs over 18-inch is important to avoid falling and injury to an individual. There are 3 stairs at the back porch that did not have handrail. This was a lapse by the maintenance, there was a previous handrail. The maintenance company has bought materials to replace the handrail, and he took the previous one out but did not install the new one. |
03/17/2025
| Implemented |
| 6400.80(b) | The outside of the building and the yard or grounds shall be well maintained, in good repair. Located at the front of the home are two basement windows that each have a plastic window well cover/guard on them. At the time of the inspection, both of the basements plastic window well covers/guards were cracked as well as missing pieces of the plastic on approximately 4 areas on each of the covers/guards. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | It is important for the upkeep of the yard and all the surroundings for health and safety. During the inspection, the basement window plastic covers were broken. Maintenance bought the covers to replace it but filled to do the replacement. |
03/06/2025
| Implemented |