| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 7/24/24, at 12:03PM, in the home's only bathroom, the caulking sealing at bathtub's edge along the wall, under the bathtub faucet and the adjoining wall had multitude of black spots that appear to be mold and/or mildew. At 12:03 PM, the entire base of the oven's interior was covered with food chards and black stains from what appears to food splatter and grease. | Clean and sanitary conditions shall be maintained in the home. | 7/24/24 staff cleaned the oven's interior. 8/16/24 maintenance recaulked the bathtubs sealing, bathtubs faucet, and adjoining wall and repainted. |
08/16/2024
| Not Implemented |
| 6400.67(a) | On 7/24/24, at 12:03PM, there is an area approximately three feet in circumference of cracked and peeling paint from what appears to be water damage on the ceiling above the shower in the only bathroom in the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | 8/16/24 Maintenance recaulked the bathtub area and repainted all surrounding areas including the ceiling and removed any traces of peeling paint. |
08/16/2024
| Not Implemented |
| 6400.68(b) | On 7/24/24, at 12:05PM, the hot water temperature at the bathtub in the home's only bathroom measured 136.8 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Temperature was adjusted by maintenance the day before inspection because it was a few degrees under 120; however, it got too hot. 7/24/24 Maintenance came to site to address the hot water temperature to ensure water temperature in bathroom and kitchen area were within range of required temperature. Maintenance revisited the site 2 days later to ensure water temperature was still within range. |
07/26/2024
| Not Implemented |
| 6400.72(a) | On 7/24/24 at 12:03 PM, there were no screens in the windows in the vacant bedroom of the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 8/16/24 Maintenance has ordered screens for the home. |
08/16/2024
| Not Implemented |
| 6400.72(b) | On 7/24/24 at 12:11 PM, the top and bottom left side of the exterior wooden frame of the inoperable door to the basement of the home was deteriorating, splitting and rotting. | Screens, windows and doors shall be in good repair. | 8/12/24 CEO contacted landlord property manager about deteriorating door. Maintenance team from property manager has been out and are waiting on landlords to approve of work completion costs. |
08/12/2024
| Not Implemented |
| 6400.80(b) | On 7/24/24 at 12:14 PM, the chain link fence in the backyard of the home was collapsed to the ground and broken in several areas along the rear and left side of the property; exposing bent, cracked metal with sharp ends posing tripping, falling and laceration hazards. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 8/12/24 CEO contacted the landlord's property manager about the deteriorating door. Maintenance team from the property manager has been out and is waiting on landlords to approve work completion costs. |
08/12/2024
| Not Implemented |
| 6400.101 | On 7/24/24 at 12:12PM, the door between the basement and the garage has a key locking mechanism on the garage side of the door posing an obstructed egress from the garage when engaged without access to a key. There is not a swing door in the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 8/16/24 Maintenance has addressed the locked door to ensure a key is provided to staff and accessible to the individual. |
08/16/2024
| Not Implemented |
| 6400.18(a)(4) | The agency became aware of an allegation of abuse on 3/18/24. Enterprise Incident Management Incident 9384919 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 3/21/24. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| COO developed EIM team to assist with entry of EIMs.Incident Manager Representative reviewed importance of reporting incidents during all staff meeting 8/5/24. A second team was created to assist with entry and completion of incidents 8/16/24. |
08/05/2024
| Not Implemented |
| 6400.18(a)(8) | Individual #1 was involved in law enforcement activity on 6/1/24. The agency did not report the incident #9426099 in Enterprise Incident Management, the Department's information management system until 6/3/24. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| COO developed EIM team to assist with entry of EIMs.Incident Manager Representative reviewed importance of reporting incidents during all staff meeting 8/5/24. A second team was created to assist with entry and completion of incidents 8/16/24. |
08/05/2024
| Not Implemented |
| 6400.18(i) | Enterprise Incident Management, Incident 9384919 for an allegation of abuse had an extension finalization due date of 6/15/24. As of 7/30/24, the incident has not been finalized or another extension has not been requested. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | COO finalized incident 9384919 7/29/24. |
08/16/2024
| Not Implemented |