| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Hand sanitizer on table. A tub of grout in bottom cabinet across from the sink unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials, including cleaning products, chemicals, and hazardous substances, shall be kept locked or otherwise made inaccessible to individuals. Hand sanitizer and grout observed unsecured will be immediately removed and stored properly |
08/30/2025
| Implemented |
| 6400.62(d) | A bottle of cooking oil was observed in the same unlocked cabinet as grout. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | All poisonous materials shall be kept separate from food, food preparation surfaces, and dining surfaces. The bottle of cooking oil observed in the same unlocked cabinet with poisonous materials will be immediately corrected by removing and storing items according to regulation. |
08/30/2025
| Implemented |
| 6400.64(a) | Individual room smelled of urine. | Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions shall be always maintained in the home. The individual bedroom observed with a urine odor will be immediately cleaned, sanitized, and inspected to ensure proper hygiene standards are restored. |
08/30/2025
| Implemented |
| 6400.64(f) | A large pile of cardboard boxes, trash bags and wood was observed in the backyard. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | During construction or remodeling of client bathrooms, all contractors and staff must ensure that trash outside the home is kept in closed receptacles that prevent the penetration of insects and rodents. The large pile of cardboard boxes, trash bags, and wood observed in the backyard were immediately removed and properly disposed of in closed containers. |
08/30/2025
| Implemented |
| 6400.65 | Windows in home were not operable. Plexi-glass nailed to windows. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Although individual behavior caused damage to the window and the ISP and BSP identified plexiglass as a preventive measure for safety, a customized replacement window is being ordered for installation. For compliance and safety, all living areas, recreation areas, individual bedrooms, kitchens, and bathrooms will have at least one operable window or approved mechanical ventilation. The plexiglass will be removed upon installation of the operable window to ensure both safety and ventilation standards are met. |
08/30/2025
| Implemented |
| 6400.67(a) | Water damaged ceiling tiles were observed in the dining room area ceiling. | Floors, walls, ceilings and other surfaces shall be in good repair. | Water-damaged ceiling tiles observed in the dining room area will be replaced immediately to restore the ceiling to good repair. All floor, wall, ceiling, and surface areas will be routinely inspected and maintained to ensure compliance and safety. |
08/30/2025
| Implemented |
| 6400.72(b) | A damaged window screen was observed in one of the rooms. | Screens, windows and doors shall be in good repair. | The damaged window screen observed in one of the rooms will be repaired or replaced immediately. All damaged windows caused by individual behavior have been custom ordered and are being replaced to ensure compliance. All screens, windows, and doors will be maintained in good repair to provide safety and proper function. |
08/30/2025
| Implemented |
| 6400.80(b) | Overgrown weeds were observed in the front yard obstructing the windows. Overgrown weeds were observed in the back yard obstructing the walkway and stairs | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | A professional landscaper has been hired to maintain the property on a scheduled basis to ensure weeds and overgrowth are controlled. |
08/30/2025
| Implemented |
| 6400.81(i) | Bedroom window for individual did not have any window treatment. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | The damaged window screen observed in one of the rooms will be repaired or replaced immediately. All damaged windows caused by individual behavior have been custom ordered and are being replaced to ensure compliance. All screens, windows, and doors will be maintained in good repair to provide safety and proper function. |
08/30/2025
| Implemented |
| 6400.81(k)(2) | The bedroom designated as the individual's room did not have a solid mattress or foundation, beddings, pillows, a chest or dressers, clothing racks in closet or a mirror. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | A clean, comfortable mattress and solid foundation, along with appropriate bedding and pillows, have been provided in compliance with §6400.81 (k)(2).
Due to behavioral concerns, including furniture flipping, removal of mattress covers, and wrapping pillows, furniture has been secured to the floor and walls to prevent injury and damage.
Items posing choking hazards, as requested by the parent, will be provided under guided access by staff.
The individual's chest and clothing have been placed in the adjacent bedroom, consistent with the ISP and BSP. Plexiglass barriers are used as a preventive measure to reduce risk of injury. |
08/30/2025
| Implemented |
| 6400.81(k)(4) | The bedroom designated as the individual's room did not have a solid mattress or foundation, beddings, pillows, a chest or dressers, clothing racks in closet or a mirror. | In bedrooms, each individual shall have the following: A chest of drawers. | A chest of drawers has been provided in compliance with §6400.81(k)(4).
Due to behavioral concerns (flipping furniture, removing mattress covers, wrapping pillows), safety modifications per the ISP/BSP are in place. The chest of drawers and clothing have been relocated to an adjacent bedroom under guided access, as requested by the parent, to reduce choking hazards. Plexiglass barriers are also used as preventive safety measures.
All furniture in the individual's bedroom will be secured to the floor or walls to prevent flipping and potential injury |
08/30/2025
| Implemented |
| 6400.81(k)(5) | The bedroom designated as the individual's room did not have a solid mattress or foundation, beddings, pillows, a chest or dressers, clothing racks in closet or a mirror. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Closet space with racks and shelving is available in the individual's bedroom, meeting the requirement.
Due to behavioral concerns (furniture flipping, removing mattress covers, wrapping items), the dresser and additional clothing storage were relocated to an adjacent bedroom under guided access per ISP/BSP and parent request. Plexiglass barriers are used as preventive safety measures.
All furniture in the individual's bedroom will be secured to the floor/walls to prevent flipping or injury. |
08/30/2025
| Implemented |
| 6400.81(k)(6) | The bedroom designated as the individual's room did not have a solid mattress or foundation, beddings, pillows, a chest or dressers, clothing racks in closet or a mirror. | In bedrooms, each individual shall have the following: A mirror. | A mirror has been provided for the individual's use in compliance with §6400.81(k)(6).
Due to behavioral concerns (furniture flipping, removing mattress covers, wrapping items around the neck), modifications are in place per the ISP and BSP. To ensure safety, the mirror has been installed using shatterproof, plexiglass material to reduce injury risk.
The chest and clothing remain in an adjacent bedroom under guided access at the parent's request to minimize choking hazards.
All furniture in the individual's bedroom is secured to the floor and/or walls to prevent flipping and potential injury. |
08/30/2025
| Implemented |
| 6400.171 | An open jar of salsa was found in the kitchen cabinet | Food shall be protected from contamination while being stored, prepared, transported and served.
| The open jar of salsa was immediately discarded.
All staff were reminded and retrained that once opened, food must be properly sealed, refrigerated, or discarded per food safety guidelines.
Kitchen inspections will be conducted daily by staff to ensure all food is stored appropriately. |
08/30/2025
| Implemented |