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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Service Plan, last updated 12/19/24, explains that "It is unknown whether [Individual #1] knows what danger signs or warning labels mean on poisonous substances. It is also unknown whether or not [Individual #1] would ingest a non-food item." At 12:27 PM on 6/18/25, on two open shelves in the unlocked and accessible laundry room located in the home's basement, the following unlocked cleaners and paints were found: a 24-fluid-ounce bottle of Radiance Toilet Bowl Cleaner; a 28-fluid-ounce bottle of Lysol Mult-Surface Concentrated Cleaner; a 32-fluid-ounce spray bottle of True Living Glass Cleaner; a 24-fluid-ounce spray bottle of Mr. Clean Multi-Surface Cleaner; and eight 126-fluid-ounce cans of Clark + Kensington Premium Interior Paint. [Repeat Violation-7/1/24 et al.] | Poisonous materials shall be kept locked or made inaccessible to individuals. | On06/18/2025, it was observed that cleaning products and paint cans were stored in the laundry room in the basement unlocked in violation of the regulation 6400.62(a).
Immediate Corrective Action Taken:
All poisonous materials were immediately removed from accessible areas and placed in a locked cabinet
The individual's environment was re-checked to confirm that all poisonous substances were secured.
All staff will be retrained on safe storage of poisonous materials and regulation 6400.62(a) |
07/31/2025
| Implemented |
| 6400.63(a) | On 6/18/25, at 12:16 PM, the hot water temperature at the sink in the full bathroom located in the home's basement measured 123 degrees Fahrenheit. At 12:35 PM, the hot water temperature at the kitchen sink, located on the home's main level measured 123.2 degrees Fahrenheit. | 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. | On 06/18/2025, during the licensing inspection, the hot water temperature in the home was measured at 123.2°F in the basement bathroom and 123°F in the kitchen, which exceeds the acceptable safety threshold. This creates a potential burn hazard and violates regulation 6400.63(a),
Immediate Corrective Action Taken;
The water heater thermostat was immediately adjusted on 06/18/2025 to reduce the maximum hot water temperature to a safe level.
A follow-up measurement confirmed that the hot water temperature was reduced to110°F in the basement bathroom and 111°F in the kitchen, which is within safe and acceptable limits.
All individuals in the home were monitored for safety, and no injuries were reported as a result of the elevated water temperature.
Staff will be retrained on:
How to monitor and record water temperature.
How to respond if water temperature exceeds safe limits. |
07/31/2025
| Implemented |
| 6400.101 | On 6/18/25, at 12:17 PM, the interior basement door leading to the attached garage was equipped with a keyhole lock with an interior turn latch, requiring a key to disengage it from the garage side. The attached garage does not have an exterior swing door to prevent entrapment. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| During the licensing inspection on6/18/2025, it was observed that the interior basement door leading to the attached garage was equipped with a keyhole lock with an interior turn latch, which required a key to disengage from the garage side. This configuration restricts immediate egress in the event of an emergency and is not compliant with 6400.101.
Immediate Corrective Action Taken:
On 06/25/2025, the lock was immediately removed and replaced with a keyed lock on the garage side and a turn latch on the interior side., allowing free and immediate egress.
All residents and staff were notified of the door change, and a full walkthrough was conducted to ensure no other egress pathways were obstructed or locked improperly.
All staff will be retrained on the fire safety and emergency egress requirements, including regulation 6400.101. |
07/31/2025
| Implemented |
| 6400.216(a) | On 6/18/25, at 11:44 AM, the home's staff office door was equipped with a pop lock on the inside and a push-pinhole locking system on the entry side that can disengaged with a bobby pin, paper clip, ink pen cartridge, or similar object. During an interview, the agency revealed that the staff office door lock is never engaged, as it was not during the inspection, because staff do not have an object or mechanism in which to unlock it. Inside the staff office, a closet without a door lock contained the following accessible, unlocked items: two white binders entitled, "[individual #1]---MAR Book" and "[Individual #2]---MAR Book"---both binders included the individuals' Medication Administration Records from February 2024 to June 2024 as well as other corresponding medical information. Additionally, there was black lock box of Individual #1's money inside it, totaling $104. This black lock box was unlocked with a corresponding key inserted in its keyhole. | An individual's records shall be kept locked when unattended.
| On 06/18/2025, it was observed that the staff office door was equipped with a pop lock and push-pinhole lock, which allowed the door to be locked without a key and prevented proper access from the outside. This setup violated regulation 6400.216 :
. Immediate Corrective Action Taken:
On06/25/2025 the door hardware was replaced with a key-operated lock, compliant with 6400.216.
A written justification was created and added to the home's records, stating that the office contains:
Confidential individual records,
Financial documents,
medications
hazardous materials,
and therefore must remain secured.
Keys to the office are now stored in an accessible location known to all trained staff and are readily available at all times.
All House Supervisors and DSP's will be retrained on
Regulation 6400.216(a)
When locked areas are permitted.
The difference between permitted key locks and non-compliant pop/push locks. |
07/31/2025
| Implemented |
| 6400.32(n) | On 6/18/25, at 11:43 AM, the home's only telephone was inaccessible and located in the staff office. Neither of the individuals residing at the home has restrictive procedure plans approved by a human rights team, limiting their right to unrestricted and private access to telecommunications. | An individual has the right to unrestricted and private access to telecommunications. | The telephone was located in a staff office, which was not accessible to the individual, thereby limiting their ability to use telecommunications independently and privately.
Immediate Corrective Action Taken:
Upon discovery of the violation, the phone was immediately relocated to an area that is accessible in the common area (Livingroom)
The individuals were informed of their right to use the phone without restriction and given instruction on how to use it in the new location.
All staff will be retrained on individual rights, specifically 6400.32(n), focusing on access to telecommunications, . |
07/31/2025
| Implemented |
| 6400.32(r)(1) | On 6/18/25, at 12:04 PM, the door lock to Individual #1's bedroom was equipped with a pop lock on the inside and a push-pinhole locking system on the entry side. Individual #1 does not have a unique mechanism or entry device to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | During the licensing inspection on 06/18/2025, it was observed that Individual #1's bedroom door was equipped with a pop lock on the inside and a push-pinhole unlocking system on the outside. This configuration does not meet the regulatory requirement because:
It does not reliably allow staff to gain access in an emergency.
It does not fully support the individual's right to a secure and operable locking mechanism that maintains privacy and safety.
Immediate Corrective Action Taken:
On 06/25/2025, the current locking hardware was removed and replaced with a privacy lock set with a key override, allowing the individual to lock and unlock their door independently.
Staff to access the room quickly with a master key in emergency situations.
Individual #1 was informed of the change and shown how to use the new lock and given a copy of the key.
Staff were informed that the key is stored in a clearly labeled, secure, and accessible location on-site.
Staff will be retrained on :
Individual rights to bedroom privacy.
Proper use and emergency access procedures for locking mechanisms.
Location of override keys. |
07/31/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 8/3/22, the bathroom in the basement did not have operable lighting. On 8/3/22, the garage area did not have operable lighting, there was no light bulb in the light fixture. On 8/3/22, there was no operable lighting outside of the basement exit. When the light switch was utilized, the lighting fixture did not turn on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Lighting is operable in the basement bathroom, garage as well as the light outside the basement door. All light bulbs have been replaced. [Training form, dated 9/20/22, on the requirements related to proper lighting was received on 9/23/22 and reviewed 9/28/22. The Monthly Site Audit form template was received on 9/23/22 and reviewed 9/28/22. Verification of operable lighting via pictures was received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
| 6400.82(f) | On 8/3/22, the bathroom located in the basement did not have soap available. Additionally, the basement bathroom did not have individual clean paper or cloth towels available. | 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. | Soap and paper towels were put into the basement bathroom. [Training document, dated 9/20/22, on required components of all bathrooms received on 9/23/22 and reviewed on 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
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