| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There were knobs missing on the bathroom cabinet. | Floors, walls, ceilings and other surfaces shall be in good repair. | All missing knobs on the bathroom cabinets have been replaced. See documentation attached. |
08/21/2025
| Implemented |
| 6400.67(b) | The paint in individual 1's bedroom was peeling from the ceiling to the floor next to the door jam. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The door and door frame were replaced and repainted. The walls around the door were also painted. |
08/25/2025
| Implemented |
| 6400.68(b) | The water in the home was tested and found to be 134 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Boiler was reset to "A" by our workman and temperature rechecked in all bathtubs, kitchen and showers. Temp now below 120 degree Fahrenheit, (see photo attached)
As of the time of this report, a new temp was taken 10/08/25@11.45 105.5degreea Fahrenheit |
08/21/2025
| Implemented |
| 6400.112(a) | The Drills conducted after the move in day are dated 4/7, 5/6, 6/4, 7/8and 8/4 are all documented with the former address of 914 south Avenue, apt G 33, the evacuation exit Hallway and meeting place (under the tree), this is the exact information for the former residence. | An unannounced fire drill shall be held at least once a month. | An overnight drill was conducted on the 08/21/2025 at 1.45am.
An unannounced drill was conducted at the time of this report: 10/08/2025 |
08/21/2025
| Implemented |
| 6400.142(a) | Individual 2 - Last dental appointment 4/24/2024, next annual appointment scheduled 4/28/2025 at 10am, not record of visit was available at time of inspection. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The dental appointment was not done because the dentist needed a new consent to be signed by individual's parent who has not been located. the agency needed to seek legal advice as to how to proceed with consent because the other named person on the consent form was the late CEO of the agency. We have been granted guardianship, and the current CEO has now signed consent which has been forwarded to the dental clinic on 10/06/25. We are awaiting a new appointment date for her. The earliest we could secure was 11/14/2025. |
11/14/2025
| Implemented |
| 6400.142(g) | Individual 2 - No dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | The dental office have been notified of a need for a dental hygiene plan. The agency nurse has also followed up with the dental office. The pan will be provided once the new appointment has been established for client and a review done. We ar awaiting a new appointment date |
10/07/2025
| Implemented |
| 6400.32(h) | The window in the bathroom was not covered by drapes or other material to maintain privacy. | An individual has the right to privacy of person and possessions. | A new window blind has been fitted. see attached photo |
08/21/2025
| Implemented |
| 6400.32(r) | The copy of the individual rights is missing the right to have a lock on individuals 2's bedroom door. | An individual has the right to lock the individual's bedroom door. | Bedroom door lock has been replaced. |
08/25/2025
| Implemented |