| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The wood paneling was loose and pulling away from the wall in the individual bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Supervisor placed a request to maintenance and the paneling was secured on 2/12/26. |
02/12/2026
| Implemented |
| 6400.112(e) | A period of greater than 6 months between sleeping hour fire drills. Most recent one occurred in May of 2025 | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight drill was completed by the Supervisor on 2/1/26. |
02/01/2026
| Implemented |
| 6400.46(b) | Staff member #1 's most recent Fire Safety training occurred in June 2024, which is greater than 1 year ago | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff member #1 is no longer employed to implement a direct corrective action. |
03/01/2026
| Implemented |