| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | Rodent droppings were observed in several kitchen cabinets and behind the refrigerator and deep freezer. | There may not be evidence of infestation of insects or rodents in the home. | All affected areas (kitchen cabinets, behind refrigerator, and deep freezer) were immediately cleaned and sanitized using appropriate disinfectants.
Food items and materials in affected cabinets were discarded if contaminated.
Appliances were moved and thoroughly cleaned behind and underneath.
A licensed pest control company was contacted, and treatment was initiated to address the infestation.
Entry points were assessed and sealed as needed to prevent further rodent access. |
04/30/2026
| Implemented |
| 6400.68(b) | The bathroom's water temperature was recorded at 126.8 degrees, which exceeded the allowable amount of 120 degrees. This was fixed within 24 hours after the inspection. (Repeat Violation) | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Maintenance will adjust the hot water heater and/or mixing valve to ensure the water temperature does
not exceed 120°F.
Water temperature will be checked in all bathrooms and kitchen sinks to ensure compliance throughout the home. The Program will implement a weekly water temperature log to monitor all sinks and showers.
Any temperature reading above 120°F will be reported immediately to management and maintenance. |
01/21/2026
| Implemented |
| 6400.72(b) | The kitchen window lacked a screen. The middle bedroom window screen appeared to be punched through. The same room also contained a cracked storm window. | Screens, windows and doors shall be in good repair. | A new screen will be installed on the kitchen window.
The damaged bedroom window screen will be replaced.
The cracked storm window will be repaired or replaced to ensure proper function and safety.
All repairs will be completed to ensure compliance with applicable health and safety standards. |
04/20/2026
| Implemented |
| 6400.76(a) | The individual's left drawer beneath the bed did not fit properly and wobbled on the track. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The drawer was repaired and properly secured to its track to ensure stability.
If repair was not sufficient, the drawer unit was replaced to ensure safe and proper function.
The furniture was inspected to confirm it is now stable and safe for use. |
01/30/2026
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A thermometer was purchased and added to the first aid kit to ensure it meets regulatory requirements.
The first aid kit was reviewed to confirm that all required contents are present and complete. |
01/21/2026
| Implemented |
| 6400.104 | ·There was no notification letter to the Fire Department. | 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.
| A notification letter was completed and sent to the local fire department informing them of the home's occupancy and use.
Documentation of the notification has been maintained on file for review |
01/21/2026
| Implemented |
| 6400.106 | No furnace inspection was found in the binder | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| licensed HVAC professional was scheduled and completed a furnace inspection and cleaning.
Documentation of the inspection was obtained and placed in the facility binder for review. |
01/21/2026
| Implemented |
| 6400.111(a) | The basement fire extinguisher's gauge indicated that it was under-pressurized. This was corrected within 24 hours after the inspection. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The under-pressured fire extinguisher was replaced or recharged within 24 hours of the inspection.
The extinguisher was verified to be fully operational and properly pressurized.
All other fire extinguishers in the home were checked to ensure compliance. |
01/22/2026
| Implemented |
| 6400.112(a) | ·There were no December 2025 drill was not located in the binder. | An unannounced fire drill shall be held at least once a month. | Documentation for the December 2025 fire drill was completed and placed in the binder within 24 hours of the inspection.
The binder was reviewed to ensure all required fire drill records are present and up to date. |
01/21/2026
| Implemented |