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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is no lighting outside the basement door. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Our maintenance man put a light outside the basement door. |
12/27/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency complete a self-assessment of the home on 02/04/21. The home's certificate of compliance expired on 09/12/20. | 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.
| Sunrise RCS administrative staff was retrained on "Conducting Self-Assessment of Homes", specifically on the required timeframe for completing the assessment. This training was conducted by Oladmeji Owolabi, CEO, on 2/8/2021. Sunrise RCS will have a self assessment completed for all homes, with 3 to 6 months prior to the expiration date of our most recently issued Certificate of Compliance. Timely completion of self assessments will be ensured by Oladimeji Owolabi.[Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of the self-assessments for each home. Upon completion of the self-assessments, the CEO shall audit the self-assessments to ensure accurate, full and timely completion. Documentation of the audits by the CEO shall be kept. (DPOC by AES,HSLS on 2/16/21)] |
02/08/2021
| Implemented |
| 6400.112(d) | The fire drill conducted on 12/5/2020 had an evacuation time of 2 minutes and 38 seconds. The home does not have an extended evacuation time. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Sunrise RCS will conduct a training for all Direct Care Staff, on the importance of having an evacuation time within 2 1/2 minutes during fire drills. This training will be held across multiple dates in an effort to accommodate staff schedules, but will occur between the dates of 2/8 and 2/12/21. The training will be held by Chourouk Taoufiq, Program Manager, who will also be responsible for evaluating evacuation times for fire drills. [At least quarterly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drill are conducted and documented as required. Documentation of the audits shall be kept. Staff shall be educated on conducting and documenting fire drills as needed upon the aforementioned fire drill records. (DPOC by AES, HSLS on 2/16/21)] |
02/12/2021
| Implemented |
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