| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The sealant between the bathtub and the wall tile was discolored in places consistent with black mold. | Clean and sanitary conditions shall be maintained in the home. | Root Cause:
Moisture had accumulated in the caulking between the bathtub and tile, causing discoloration and mold growth. This area is prone to moisture retention, and the discoloration was not previously identified by staff during routine cleaning.
Immediate Corrective Action Taken:
The discolored and mold-affected caulking was removed and replaced with new, mildew-resistant sealant.
The bathtub and surrounding tile were deep cleaned and sanitized using mold/mildew removal products.
The Program Manager inspected the area to confirm the mold was fully eliminated. |
10/30/2025
| Implemented |
| 6400.65 | There was no ventilation in the bathroom; there was no exhaust fan and the skylight did not open. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Root Cause:
The bathroom skylight is designed to open; however, the opening chain was stuck, and staff did not identify that the chain had become jammed.
Immediate Corrective Action Taken:
The skylight chain was repaired and unstuck, allowing the skylight to open fully for ventilation. |
10/30/2025
| Implemented |
| 6400.67(b) | The linoleum on the basement floor was loose and curling upwards causing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Root Cause:
Over time, moisture and temperature changes in the basement caused the adhesive under the linoleum to weaken. This resulted in the flooring becoming loose and curling at the edges. Staff had not previously identified the hazard because the basement is rarely accessed.
Immediate Corrective Action Taken:
The loose and curling section of linoleum was repaired by adding more adhesive and making the flooring securely.
The area where the hazard was identified was made safe immediately and remains hazard-free. |
10/30/2025
| Implemented |