| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The second floor bathroom shower had a knob that spun loosely and prevented the water from flowing and the water temperature from being checked. | Floors, walls, ceilings and other surfaces shall be in good repair. | Knob has been replaced. |
08/28/2026
| Implemented |
| 6400.67(b) | A junction box on the basement ceiling was uncovered exposing electrical wiring. A fallen wire was wrapped around the HVAC condenser in the yard of the residence. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Junction box has been covered and wires placed appropriately and safely. (see shared folder) |
08/20/2026
| Implemented |
| 6400.71 | The emergency contacts listed hospitals that were closed. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| New updated emergency contact list showing currently opened hospital have been placed in the house. see shared folder |
08/14/2026
| Implemented |
| 6400.74 | Anti-skid material was missing from the basement steps. | Interior stairs and outside steps shall have a nonskid surface.
| Interior and exterior stairs fitted with anti-skid carpets. (see shared folder) |
08/21/2026
| Implemented |
| 6400.82(f) | The basement bathroom was missing toilet paper and paper 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. | Toilet paper and paper towel fitted in the basement bathroom.(see shared folder) |
08/14/2026
| Implemented |
| 6400.110(e) | The interconnected fire alarms did not sound together when activated. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | interconnected smoke detector has been installed (see shared folder) |
08/21/2026
| Implemented |
| 6400.112(d) | 4 of the 12 fire drills in the past year exceeded the two minute-thirty second requirement and did not have additional drills recorded in the month to achieve the required evacuation time.
Drills recorded:
08/04/2026 -- 2 minutes 64 seconds
04/12/2026 -- 2 minutes 48 seconds
03/06/2026 -- 1 minute 98 seconds
12/12/2025 -- 2 minutes 38 seconds | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Staff have been retrained on how to carry out a proper fire drill and the time expected.
A new fire drill was done to identify training instructions were effective.
(see shared folder) |
08/24/2026
| Implemented |