| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1 requires assistance managing finances. The home is not keeping an up-to-date financial and property record that includes the following: personal possessions and funds received by or deposited with the family or home; and disbursements made to or for Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | An Individual Money Form will be completed to log all expenses and deposits for Individual #1. Receipts will be obtained, copied, and filed for record-keeping, while original receipts will be submitted to Individual #1¿s guardian as requested. |
12/16/2024
| Implemented |
| 6400.22(d)(2) | Individual #1 requires assistance managing finances. The home is not keeping an up-to-date financial and property record that includes disbursements made to or for Individual #1. | (2) Disbursements made to or for the individual.
| An Individual Money Form will be completed to log all deposits and disbursements for Individual #1. Receipts for all transactions will be obtained, copied, and filed to ensure proper documentation and verification of financial activities. Staff will be trained on the accurate and timely recording of financial records. |
12/16/2024
| Implemented |
| 6400.64(a) | At 12:31PM, the inside of the oven was covered with food chards and black stains. At 12:55PM, there were black areas from what appeared to be mold and/or mildew on the caulking below faucet, the front interior and on the ceiling along the back wall of the bathtub in the bathroom on the first floor of the home. In addition, the exhaust fan vent cover in this bathroom was coated in dust and debris. At 1:00 PM, the floor vent in the home's staff office was covered in thick layers of dust and debris. At 2:20 PM, there were five empty toilet paper rolls and discarded crumbled toilet paper underneath the vanity sink of the bathroom on the second floor of the home. In addition, the exhaust fan vent cover in this bathroom was coated in dust and debris. | Clean and sanitary conditions shall be maintained in the home. | We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.64(f) | At 12:20PM, the following discarded items were strewn about the yard on the side of the home outside of the trash receptacles: an empty Mt. Dew cardboard box; a large Room Essentials Futon cardboard box filled with various objects, including plastic wrap protruding outward from its top; two empty Minute Maid plastic juice containers; an empty Styrofoam food container; crumpled up fast food paper bags; an empty Wendy's plastic cup; plastic and paper wrap; a window frame with a broken pane; and a window screen leaning against the home's air-conditioning compressor unit.[Repeated violation 7/23/2024 et al.] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | To address the absence of lids on trash receptacles, we are replacing all bins without attached lids across bathrooms, kitchens, and outdoor areas with step-on/hinged trash cans. Additionally, an order for outdoor trash cans with hinged lids has been placed with Home Depot to prevent insect and rodent access. Residential site supervisors will conduct weekly inspections to verify the presence and proper closure of all receptacles. |
12/16/2024
| Not Implemented |
| 6400.67(a) | At 12:28 PM, a one-foot, by one-foot, by one-foot, hole was in the wall at the bottom of the stairs leading to the upper level. At 12:33 PM, the drawer to the left of the kitchen sink was missing a faceplate and corresponding handles. At 12:44 PM, two and a half feet by one and a half feet hole was in the wall to the right of the front door. At 12:45PM, a one-foot diameter hole was in the wall adjacent to the stairs in the living room of home. At 2:09 PM, the three holes, measuring eight inches by eight inches; twelve feet by seven inches; and ten inches by 6 inches were in the walls of the stairwell leading to the second floor of the home. At 2:16 PM, a fourteen-inch crack was on the wall to the right of Individual #1's bedroom doorway. At 2:18 PM, a seven-inch crack was on the wall adjacent to the toilet in the bathroom on the second floor of the home. Additionally, when facing the entry from inside this bathroom, the bottom and middle sections of left-side door trim were separated and removed from the doorframe. | Floors, walls, ceilings and other surfaces shall be in good repair. | 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
| Not Implemented |
| 6400.67(b) | At 1:50 PM, the basement's center floor drain was missing a sewer grate cover, exposing a circular hole measuring six inches in diameter, posing a tripping hazard. At 2:00 PM, the left and right glass panes of the attached garage's only window were cracked in several areas and busted out completely, exposing to sharp edges; posing a laceration hazard. Additionally, shards of broken glass from this window were scattered over the garage floor. At 2:20 PM, the paint on the ceiling and wall near the shower head of the full bathroom on the second story of the home, was bubbling, flaking, and peeling in thick layers, and suspended vertically over the front portion of the shower stall, encompassing an area of two feet by six inches. Additionally, on the ceiling directly above the showerhead were several pink, circular spots appearing to be bacteria. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 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
| Not Implemented |
| 6400.68(b) | At 12:50 PM, the hot water temperature measured 127.2 degrees Fahrenheit at the bathtub in the bathroom on the first floor of the home. At 2:22 PM, the hot water temperature measured 126.1 degrees Fahrenheit at the bathtub in the bathroom located on the second floor of the home.[Repeated violation 7/23/2024 et al.] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Provider¿s Plan of Correction: To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. |
12/16/2024
| Not Implemented |
| 6400.72(a) | At 12:58 PM, both windows in the staff office of the home did not have screens.[Repeated violation 7/23/2024 et al.] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 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
| Not Implemented |
| 6400.72(b) | At 1:50 PM, the doorknob on the interior basement door leading into the attached garage was loose and separated from the door's structure. At 2:00 PM, the left and right glass panes of the attached garage's window were cracked and missing glass. At 2:13 PM, the door of the vacant bedroom was detached from the top hinge and leaning inward.[Repeated violation 7/23/2024 et al.] | Screens, windows and doors shall be in good repair. | 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
| Not Implemented |
| 6400.72(c) | At 1:50PM, the outside door from the basement of the home did not have an operable lock. | Outside doors shall have operable locks. | 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 |
| 6400.73(a) | At 2:06 PM, the top section of the railing along the basement stairs was loose, unsecured, and detaching from the wall. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | 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 |
| 6400.80(b) | At 12:20 PM, a rusty blue metal rod with a sharp end was wedged in between the home's gas meter and the side of the home. In addition, a cigarette butt was atop the gas meter. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 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
| Not Implemented |
| 6400.82(f) | At 12:50 PM, the bathroom on the first floor of the home did not have a mirror or trash receptacle. At 2:27 PM, the bathroom on the second floor of the home did not have a trash receptacle.[Repeated violation 7/23/2024 et al.] | 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. | To address the absence of trash receptacles, as well as prevent lid separation, we are replacing existing bins without attached lids across all bathrooms, kitchens, and outdoor areas with step-on trash cans. One order was received on October 30, with additional orders expected on November 1 and 2. Additionally, an over-the-sink mirror has been ordered and will be installed by the maintenance team upon arrival. Residential site supervisors will verify the presence and functionality of these items during weekly inspections. |
12/16/2024
| Not Implemented |
| 6400.101 | At 2:05 PM, the door between the basement and the garage had key lock mechanism on the the garage side, posing an obstructed egress from the garage without a key. There is not a swing door in the garage.[Repeated violation 7/23/2024 et al.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 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
| Not Implemented |
| 6400.105 | At 1:52 PM, an empty plastic Wendy's cup and a piece of paper were on the basement floor next to the furnace.[Repeated violation 7/23/2024 et al.] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.111(a) | There was not a fire extinguisher on the first floor of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher with a 2-A rating has been installed in the kitchen. This extinguisher will serve the first floor, ensuring compliance with the requirement for an operable extinguisher on each floor and in the kitchen. |
12/16/2024
| Implemented |
| 6400.111(c) | There was not a fire extinguisher in the kitchen of the home. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | A fire extinguisher with a 2-A rating has been installed in the kitchen. This extinguisher will serve the first floor, ensuring compliance with the requirement for an operable extinguisher on each floor and in the kitchen. |
12/16/2024
| Implemented |
| 6400.214(b) | At 1:03 PM, the most current copies of Individual #1's physical examination, dental examination, and psychological evaluation were not kept at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The current copies of Individual #1¿s assessment, individual plan, physical examination, and dental examination will be obtained and immediately placed in the home. These documents will be stored securely in the staff office to ensure accessibility and compliance. |
12/16/2024
| Not Implemented |
| 6400.32(d) | At 2:28 PM, a Bristol Stool Chart documenting the color, size, shape, type, and frequency of Individual #1's bowel movements, was posted in the hallway wall outside of the bathroom on the second floor of the home. | An individual shall be treated with dignity and respect. | To address the inappropriate display of Individual #1¿s personal health information, the Bristol Stool Chart will be immediately removed from the hallway wall. Staff have been reminded of the importance of maintaining individuals' privacy in all documentation practices, especially concerning personal health information. Moving forward, all documentation related to individual health tracking will be kept in the office accessible only to relevant staff and Individual #1. |
12/16/2024
| Implemented |
| 6400.32(n) | At 1:38 PM, Site Supervisor #1 revealed that Individual #1's telephone use is be restricted. | An individual has the right to unrestricted and private access to telecommunications. | To address this issue, the telephone will be placed in a common area of the home, allowing Individual #1 unrestricted and private access. The agency will convene with the human rights team to review and, if necessary, approve a restrictive procedure. Once approved, staff will be thoroughly trained on implementing the restrictive procedure, and the documentation will be securely stored in the staff office. |
12/16/2024
| Not Implemented |
| 6400.163(d) | At 12:36 PM, the unlocked and accessible first aid kit in a kitchen cabinet contained following medications: four packets of Ibuprofen, each containing two 200 mg tablets; two packets of Extra Strength Acetaminophen, each containing two 500 mg tablets; and two packets of Antacid, each containing two 420 mg tablets.[Repeated violation 7/23/2024 et al.] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All medications will be removed from the first aid kit. Moving forward, only individual-specific medications will be stored in the locked medication box in the staff office. This ensures that all medications remain secure and accessible only to authorized personnel. |
12/16/2024
| Not Implemented |
| 6400.194(a) | The home is locking the telephone in the staff office. Site Supervisor #1 revealed that the home is locking the telephone and restricing Individual #1 use due to Individual #1 making "frivolous calls." The agency does not have a restrictive procedure plan in place for Individual #1 that has been approved by a human rights team. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | To address this issue, the telephone will be placed in a common area of the home, allowing Individual #1 unrestricted and private access. The agency will convene with the human rights team to review and, if necessary, approve a restrictive procedure. Once approved, staff will be thoroughly trained on implementing the restrictive procedure, and the documentation will be securely stored in the staff office. |
12/16/2024
| Not Implemented |