| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The exhaust fan in the bathroom was inoperable. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The exhaust fan was replace and installed. Staff will clean and verify the fan is working at all time |
02/01/2026
| Implemented |
| 6400.104 | There was no notification to the fire department for individual 1. | 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.
| When an individual moves into a home, the agency will notify the local fire department of the exact location of the individual's bedroom if require assistance to evacuate in the event of a fire. Notification will be sent via email and/ or mail, and a copy will maintained in the individual records |
01/05/2026
| Not Accepted |
| 6400.24 | - The 05/16/2025 criminal background check for Staff 2 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews.
- The 03/04/2025 criminal background check for Staff 3 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews.
- The 08/28/2025 criminal background check for Staff 4 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The agency have a written policy requiring case-by-case review of applicants with criminal background. Each decision will consider the nature of the offense, time elapsed, relevance to position, evidence of rehabilitation, and applicable regulatory requirements. Hiring decisions and justifications will be documented and reviewed by management to ensure compliance and consistency |
01/05/2026
| Implemented |