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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | At approximately 10:40AM, Individual #1 approached licensing representatives and asked, "Are you with the state?" and then went on to ask, "Are you going to take me away from my home?". Individual #1 was informed by the licensing representatives that we were not here to take him away. At this point, Individual #1 became upset and confronted Direct Service Worker #1. Individual #1 said to Direct Service Worker #1, "I told you to quit messing with me, you're always messing with me." Direct Service Worker #1 told Individual #1, "I was just joking around." | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | To address the violation where Individual #1 felt emotionally distressed due to Direct Service Worker #1¿s actions, immediate corrective actions have been taken. An incident report will be filed in the Enterprise Incident Management (EIM) system to document the event. Direct Service Worker #1 will be removed from the site pending further review, investigation and retraining. The retraining will focus on professional boundaries, appropriate communication, and the importance of maintaining the dignity and emotional well-being of individuals under their care. |
12/16/2024
| Not Implemented |
| 6400.63(a) | At 10:59AM, the hot water temperature measured 153.1 degrees Fahrenheitat the kitchen sink. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. Additionally, maintenance will inspect the hot water heater and related pipes to assess if any insulation or protective guards are needed to prevent potential contact with high temperatures. |
12/16/2024
| Not Implemented |
| 6400.64(b) | At 10:13AM, the lower portion of the inside of the refrigerator in the kitchen of the home had approximately 50 dead insects.[Repeated violation 7/23/2024 et al.] | There may not be evidence of infestation of insects or rodents in the home. | We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.64(f) | At 10:30AM, the two open outdoor trash receptacles in the rear of the home were overflowing with discarded items. [Repeated violation 7/23/24 et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | To address the absence of lids on trash receptacles, we are replacing all bins without attached lids across bathrooms, kitchens, and outdoor areas with step-on/hinged trash cans. Additionally, an order for outdoor trash cans with hinged lids has been placed with Home Depot to prevent insect and rodent access. Residential site supervisors will conduct weekly inspections to verify the presence and proper closure of all receptacles. |
12/16/2024
| Not Implemented |
| 6400.65 | At 10:58AM, the wall vent in the living room had a thick built-up layer of dust. [Repeated violation 7/23/24 et al] | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.67(a) | At 10:21AM, there was an eight-feet and ten-inch by three and a half feet hole in the basement ceiling. | Floors, walls, ceilings and other surfaces shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.68(b) | At 11:06AM, the hot water temperature measured 151.1 degrees Fahrenheit at the first-floor bathtub. [Repeated violation 7/23/24 et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. |
12/16/2024
| Not Implemented |
| 6400.72(a) | At 10:31AM, the rear sliding door did not have a screen door. [Repeated violation 7/23/24 et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.72(b) | At 10:48AM, the window screen, in the bathroom in the basement, had a two-inch by two-inch hole. [Repeated violation 7/23/24 et al] | Screens, windows and doors shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.73(a) | At 10:00AM, the handrail in the front of the home was not sturdy and able to be moved approximately one to two inches from side to side. At 10:29AM, the handrail in the rear of the home is positioned two feet from the steps. This handrail also does not go the full length of the steps and stops before the last three steps.[Repeated violation 7/23/2024 et al.] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.74 | At 10:29AM, the steps in the rear of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Implemented |
| 6400.76(c) | At 10:45AM, the dining room chairs were sagging approximately two inches with no cushion in the middle of the seat. | Furniture shall be comfortable and home-like. | To address the uncomfortable and sagging dining room chairs, replacement chairs with adequate cushioning will be ordered to provide a comfortable, home-like seating experience for individuals. Maintenance staff will install the new chairs upon arrival and ensure they meet comfort standards. |
12/16/2024
| Not Implemented |
| 6400.80(b) | At 10:31AM, in the rear of the home there were two trash receptacles that were overturned on their side which contained discarded items. In this area and throughout the rear of the home, there was garbage strewn across the ground. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.105 | At 10:25AM, the dryer lint trap was completely full, with a thick layer of lint. At 10:26AM, a laundry basket full of clothes was placed within an inch of the natural gas furnace.[Repeated violation 7/23/2024 et al.] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.114(b) | At 10:30AM, multiple cigarette butts were on the ground with no receptacle on the property. The smoking policy of the agency states that staff or visitors are to properly dispose of all cigarette butts in a receptacle with a lid. [Repeated violation 7/23/24 et al] | Written smoking safety procedures shall be followed. | To address the improper disposal of cigarette butts, a designated outdoor receptacle with a lid has been ordered and will be placed in an accessible location on the property for proper disposal of cigarette waste. Staff have been reminded of the agency's smoking policy, which requires all cigarette butts to be disposed of in a designated receptacle. Residential Site Supervisors will verify the installation and appropriate location of the receptacle. |
12/16/2024
| Not Implemented |
| 6400.171 | At 10:12AM, the following items were in the refrigerator in the kitchen of the home: Deli style turkey breast with a best by date of 6/28/24, Deli style smoked uncured ham with a best by date of 6/17/24, Oscar Meyer deli fresh oven roasted turkey breast with a best by date of 4/1/24. In addition, a bag of beef hamburger patties with hole in the bag and two hamburger patties were unwrapped and outside of the bag in the freezer of the refrigerator in the kitchen of the home. At 10:13AM, a partial bag of bread with a best by date of 9/18/24 was on top of the refrigerator in the kitchen of the home. At 11:16AM, five Chicken nuggets were in air fryer with other dried up food remnants. [Repeated violation 7/23/24 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| To address improper food storage practices, all expired and improperly stored items in the refrigerator, freezer, and kitchen area were immediately discarded. Staff have been reminded of food storage protocols, including checking expiration dates and ensuring food is wrapped and protected from contamination. Additionally, a food safety flyer has been created and will be posted in the kitchen as a reminder of proper storage practices. Residential Site Supervisors will monitor food storage during their weekly inspections to ensure compliance. |
12/16/2024
| Not Implemented |
| 6400.186 | In the general health and safety risks of Individual #1's individual plan, last updated on 9/30/24 reads [Individual #1] needs monitored around sharp objects since he may use it to hurt someone else if he became aggressive." In the safety precaution section of this individual plan, reads "sharp objects are put away or locked for the safety of others." At 10:15AM, a pair of scissors, a knife, and a pizza cutter were unlocked and accessible in a kitchen drawer. There were multiple thumb tacks in wall in the living room area, and a bag of screws were behind refrigerator on the window ledge. [Repeated violation 7/23/24 et al] | The home shall implement the individual plan, including revisions. | All sharp objects, including scissors, knives, and pizza cutters, will be secured in a locked cabinet within the staff office. Thumb tacks will be removed from the walls, and the bag of screws will be securely stored in the staff office. A Residential Site Supervisor will inspect the entire premises to ensure no additional sharp objects or hazardous materials are accessible. |
12/16/2024
| Not Implemented |
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