| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | Hand sanitizer and Ocean Spray juice were found stored together in a closet. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Support staff had stored the hand sanitizer in the pantry closet instead of with the chemical supply closet.
On 5/11/23 the hand sanitizer was immediately removed by staff from the pantry closet. Staff was re-educated on the proper storing of poisnous materials. |
05/11/2023
| Implemented |
| 6400.64(a) | Food waste was found in the broiler tray -- frozen French fries and grease build-up. | Clean and sanitary conditions shall be maintained in the home. | upport staff failed to clean the broiler after each meal resulting in the food and grease build up in the broiler. 5/11/23-support staff cleaned out the broiler from any food and grease buiild. |
05/11/2023
| Implemented |
| 6400.81(k)(6) | There is no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | The program manager removed the mirror for a consumer's safety without promptly installin the plastic mirror in the bedroom.
On 5/11/23, individual #1's mirror was replaced with a plexiglass mirror their safety. |
05/11/2023
| Implemented |
| 6400.112(c) | None of the fire drills conducted at this location state how long it took for the occupants to evacuate. | 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. | Support staff failed to note the evacuation time of the monthly fire drill on the form.
On 5/11/23, the program manager re-educated support staff on completing the monthly fire drill form On 5/12/23, the program support staff completed another monthly fire drill at 12:15am with the evacuation time of 2 (two) minutes. |
05/11/2023
| Implemented |
| 6400.112(e) | An overnight fire drill was not held at this location in the past 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | The program manager failed to have a tickler syetem in place as a reminder to completed an overnight fire drill every six months.
On 5/12/23, an overnight fire drill was completed for the program. |
05/12/0203
| Implemented |