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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home completed a self-assessment on 1/3/2025. The following 6400 regulations were left blank and not assessed: 11, 21a, 31g, 33a, 81l, 142d, 142e, 142g, 142h, 186, 195a, 207(3), 212, 240c, 251a, 251b, 261a, 261b1, 261b2, 261b3, 261b4, 261b5, 262b1, 262b2, 262b3, 262b4, 262b5, 263, 262a, 271(2), 272, 273(1), and 275. [Repeated violation: 7/23/2024 et al] | 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.
| The facility did not complete a self-assessment at least three to six months before the expiration of the certificate of compliance as required. To correct this issue, a formal self-assessment schedule will be implemented to ensure timely completion moving forward. By April 21, 2025, the facility will establish a compliance tracking system, and the Director of Operations is overseeing its implementation. Staff is being trained on self-assessment procedures by April 30, 2025, and internal audits is being conducted monthly to ensure continued compliance.
OCS has implemented a structured self-assessment process for each home within the required 3 to 6 months before the expiration of the compliance certificate. A compliance review team consisting of two Program Specialist, Residential Director, Compliance Director, Assigned Lead¿s/DSP¿s is conducting assessments and is documenting all findings. Training on self-assessment procedures will be completed by April 21, 2025, with ongoing quarterly reviews to ensure future compliance.
Corrective Actions:
¿ Training staff on the new structured self-assessment process
¿ Created a self-assessment tracking document that will alert staff and management when the assessments are getting close to the compliance certificate due date within 6 months and three months of renewal. |
05/30/2025
| Not Implemented |
| 6400.72(a) | On 2/25/2025 at 2:33pm, there was not a screen in the operable window in the hallway on the main level of the home. [Repeated violation: 7/23/2024 et al, 10/7/2024, 11/21/2024, and 1/23/2025] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The inspection identified windows and/or doors that were not in good repair or did not open and close properly. To address this, all windows and doors will be inspected by maintenance staff, and necessary repairs will be completed by April 15, 2025. A monthly maintenance checklist will be developed to prevent future non-compliance, and staff will be trained to report any issues immediately to Residential Directors and Maintenance.
Corrective Actions:
¿ Maintenance is inspecting all locks and doors to ensure doors lock and shut properly.
¿ Maintenance is fixing all damaged doors and windows.
¿ Leads are reporting all damaged windows, doors and locks to Residential Directors and maintenance. |
05/30/2025
| Not Implemented |
| 6400.110(b) | On 2/25/2025 at 2:38pm, the closest smoke detector in the living room of the home was more than 15 feet from the vacant bedroom. [Repeated violation: 7/23/2024 et al] | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | It was found that the facility did not have properly placed smoke detectors on each floor, including the basement and attic, where applicable. To correct this, additional smoke detectors will be installed by April 25, 2025, in all required locations. Maintenance staff will test all smoke detectors monthly, and documentation will be maintained to verify compliance. Fire safety training will be provided to staff by April 15, 2025, and fire drills will be conducted quarterly to ensure all safety measures are in place.
Corrective Actions:
¿ Smoke detectors is being inspected, and non-functioning units is being discarded and replaced by March 30, 2025.
¿ Smoke detectors have been placed on each floor and including the basement of all facilities.
¿ Fire Drills is being conducted unannounced monthly varying in time and date.
¿ Fire Safety training is ongoing to ensure clients are safe and are aware of the safety procedures as staff is aware. |
05/30/2025
| Not Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At 3:25PM, the overhead ceiling light, in the bedroom of the home, flickered on and off when turned on at the light switch on the wall. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Implemented |
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