| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Bar soap was observed in Individual #1's shower, and hand soaps were found in the 2nd floor hallway bathroom, and 1st floor laundry room bathroom. Individual #1's ISP states they have a Pica diagnosis, and it is, "important to keep poisonous substances out of reach and locked away to ensure (their) safety." | Poisonous materials shall be kept locked or made inaccessible to individuals. | All regular chemical-based soaps have been removed from the premises and replaced with all-natural, non-toxic alternatives. Remaining cleaning agents that could be considered hazardous are stored in locked cabinets away from food preparation and dining areas. Staff have been trained on identifying and handling poisonous materials and safe storage practices |
12/12/2025
| Implemented |
| 6400.64(a) | The home is in need of deep cleaning. The light switches in Individual #1's bedroom and the 2nd floor bathroom are visibly dirty. Dust was visible on various baseboards, floors, and vents, and kitchen cabinets and appliances felt greasy to the touch. | Clean and sanitary conditions shall be maintained in the home. | All staff have been retrained on proper deep cleaning procedures to ensure a safe and sanitary environment. The House Manager will conduct bi-weekly inspections using the designated site check form to verify compliance with cleaning standards and identify any areas requiring corrective action. Any deficiencies noted will be documented and addressed promptly to maintain regulatory compliance. |
12/03/2025
| Implemented |
| 6400.64(b) | Several glue-box insect traps were observed in the dining and kitchen area. A live insect and dead insect were also found in the basement area. The home provided a pest control invoice dated 10/28/25, concentrating on the kitchen area. | There may not be evidence of infestation of insects or rodents in the home. | An exterminator provided treatment for the home on October 28, 2025. A follow-up inspection was completed on November 19, 2025, and no pest activity was found. Documentation of both visits has been maintained, |
12/03/2025
| Implemented |
| 6400.70 | The home telephone was non-operable at the time of the visit. This was corrected on the day of inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| A fully charged, unlocked cell phone has been added to remain on-site at all times. The phone includes the phone number and full address stored for quick access in case of emergency |
12/03/2025
| Implemented |
| 6400.186 | Individual #1's ISP states they have a Pica diagnosis, and it is, "important to keep poisonous substances out of reach and locked away to ensure (their) safety." The ISP specifically mentions rubber gloves, of which a pair was found in an unlocked kitchen drawer. Also observed in the home were small, unsecured objects like a loose battery, pens/caps, and a glue stick (kitchen drawer) and two loose screws (basement steps). | The home shall implement the individual plan, including revisions. | All staff have been retrained on Pica and the Individual Support Plan (ISP).12-12-2025. The home was thoroughly inspected and cleared of all potential hazards. Staff received additional training to ensure that no items are stored in unlocked drawers or other unsecured areas, in order to maintain the safety of the individual. |
12/03/2025
| Implemented |