| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agencies expiration date of their certificate of compliance is 3/4/25. The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/4/24 to 1/4/25, and the self- assessment was completed 1/31/25. This exceeds the requirement. Per the Regulatory Compliance Guide (RCG) there is no grace period for this regulation. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| This reg. is important to measure the record compliance with the chapter
AppleButter When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 |
03/06/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, in the kitchen located inside the 2nd drawer to the left of the stove was approximately 20 loose grains of white rice in the bottom of the drawer. The loose rice could lead to infestation of bugs or rodents. Agency staff did clean up rice from inside the drawer and throw them out. | Clean and sanitary conditions shall be maintained in the home. | It is important to have a clean and sanitary home to avoid infestation or pests. At the time of the inspection, there were some loose grains of rice in the kitchen cabinet. That was a spill that staff did not take time to properly clean it. This was corrected at the time of the licensing. |
03/14/2025
| Implemented |
| 6400.80(a) | At the time of the inspection, when stepping out the back door of the home there were 8 loose bricks that you would step on as soon as you exited the home, that were not affixed to one another or the concrete landing/patio. Due to the 8 bricks not being affixed to anything and just being placed on top of the concrete patio/landing when the Licensing Representative (LR) stepped directly onto the bricks they wobbled back and forth under the LR's feet. The bricks being pose a potential tripping hazard when someone would be exiting the home through the back door. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | It is essential that all walkways should be free from obstructions to prevent fall.
There were some loose bricks in the walkway from the back door of the home. Maintenance dug the bricks out when working on the septic in the back of the home, due to the cold weather, they could not cement the bricks. Therefore, they laid it with dirt to support it until the weather can be conducive for cement. My maintenance was able to remove all the bricks, and the walkway is not hazardous. |
03/14/2025
| Implemented |
| 6400.104 | There was a letter notifying the local fire department dated 7/9/23 and it noted that 2 individuals presently occupy the home. However, the agency decreased the home capacity to a 1-person home and the effective approval Program Capacity date was 9/28/24. There was no record or documentation that an updated notification letter was sent to the local fire department with the change in capacity of the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Notification to fire department is essential so that fire Marshalls are aware in case there is actual fire. At the time of the inspection, the inspector did not see a second letter showing there was a change in capacity. This was an error that the second letter was not in the fire drill book. There was a new letter written to the fire department. |
03/06/2025
| Implemented |