| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | A plain spray bottle was observed under the kitchen sink with a handwritten label identifying it as "bleach and water." The liquid was not stored in the original container. | Poisonous materials shall be stored in their original, labeled containers. | WHO:
The House Manager is responsible for correcting and overseeing this issue.
WHAT:
A plain spray bottle containing bleach and water that was not stored in its original manufacturer-labeled container.
WHEN & HOW:
Immediately upon identification, the spray bottle was removed from under the kitchen sink and disposed of.
All cleaning and poisonous materials are in their original, manufacturer-labeled containers in accordance with ODP regulations.
The Program Supervisor conducted an immediate inspection of all storage areas within the home and other homes through CCS to ensure no other non-original containers containing hazardous materials were present.
No additional concerns were identified.
Target Date for Completion: 12/19/2025 |
12/18/2025
| Implemented |
| 6400.64(a) | Cobwebs were observed on the dining room window. The dining room walls have black scuff marks that appear to be from furniture. The oven is dirty with baked grease found at the bottom of the unit. Kitchen cabinet doors had visible dirt and or food on the front panels. | Clean and sanitary conditions shall be maintained in the home. | WHO:
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Cobwebs were present on the dining room window; black scuff marks were observed on the dining room walls from furniture; and the oven was dirty with baked-on grease at the bottom of the unit, resulting in the home not being maintained in clean and sanitary condition.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the dining room window was cleaned and all cobwebs were removed.
Dining room walls were cleaned to remove black scuff marks caused by furniture.
The oven was thoroughly cleaned to remove all baked-on grease.
The Program Supervisor conducted an inspection of all common areas and kitchen spaces to ensure no additional sanitation concerns were present.
No further issues were identified.
Supervised by Program Specialist to ensure completion. |
12/18/2025
| Implemented |
| 6400.76(a) | The legs on the desk in the dining room were shaky, making the desk unstable. | Furniture and equipment shall be nonhazardous, clean and sturdy. | WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
The dining room desk had shaky legs, making the furniture unstable and not sturdy as required.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the desk was removed from use to eliminate any potential safety hazard.
Personnel from the maintenance department assessed the desk and arranged for repair or replacement to ensure it is stable, sturdy, and nonhazardous prior to being returned to use.
An inspection of all dining room and common-area furniture was conducted to determine whether any additional furniture was unstable or unsafe.
No additional furniture concerns were identified. |
12/18/2025
| Implemented |
| 6400.81(k)(6) | An individual's bedroom was not equipped with a mirror. | In bedrooms, each individual shall have the following: A mirror. | WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
An individual's bedroom was not equipped with a mirror as required by ODP regulations.
WHEN & HOW (Corrective Actions):
Immediately upon identification, a mirror was obtained and installed in the individual's bedroom in a safe, accessible, and appropriate location.
The Program Supervisor verified that the mirror was securely mounted and met safety requirements.
A review of all bedrooms in the home was conducted to ensure that each bedroom was equipped with a mirror as required.
No additional deficiencies were identified.
Target Date for Completion: 12/18/2026. |
12/18/2025
| Implemented |
| 6400.82(f) | The home bathroom was not equipped with individual paper towels or hand towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Plan of Correction -- Immediate Correction
WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
The home bathroom was not equipped with individual paper towels or clean hand towels as required by ODP regulations.
WHEN & HOW (Corrective Actions):
Immediately upon identification, individual paper towels and/or clean individual hand towels were placed in the bathroom to meet regulatory requirements.
The Program Supervisor verified that all required bathroom items (sink, wall mirror, soap, toilet paper, individual towels, and trash receptacle) were present and accessible.
A review of all bathrooms in the home was conducted to ensure compliance beyond the cited sample.
No additional deficiencies were identified.
Target Date for Completion: 12/18/2025 and ongoing monitoring. |
12/18/2025
| Implemented |
| 6400.151(a) | Staff #1 was hired on 06/30/25. Their initial physical examination was completed on 05/14/24, and Tuberculin test was completed on 06/15/23, which exceeds the maximum allowable timeframe of no more than one year prior to date of hire. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | WHO (Responsible Party):
The Human Resources Manager responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Staff #1 was hired on 06/30/2025; however, the initial physical examination dated 05/14/2024 and Tuberculin (TB) test dated 06/15/2023 exceeded the maximum allowable timeframe of no more than one year prior to the date of hire.
WHEN & HOW (Corrective Actions):
This specific noncompliance cannot be retroactively corrected, as the hire date has already passed.
Upon identification, the provider documented the deficiency and reviewed Staff #1's file to ensure there were no current health or safety concerns related to the outdated documentation.
The Human Resources Manager conducted a review of all current staff personnel files to determine whether any additional staff were out of compliance with physical and TB timeframe requirements.
No additional deficiencies were identified. |
12/30/2025
| Implemented |