| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.74 | The steps to the basement did not have anti-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| a. WHO: Administrative Staff
b. WHAT: Interior stairs and outside steps shall have a nonskid surface.
c. WHEN and HOW
· Placed nonskid carpet on the steps to the basement
There is no other violation
· Target dates:1/27/26
· Specific dates:1/29/26
2. A plan to prevent future occurrences
· By routinely inspecting stairs and steps and promptly installing and maintaining approved nonskid surfaces on all interior and exterior stairways. |
01/29/2026
| Implemented |
| 6400.104 | The notification to the fire department does not include the location of individual's bedroom. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| WHO: Administrative Staff
b. WHAT: The notification to the fire department does not include the location of individual's bedroom.
c. WHEN and HOW
· The letter was modified to reflect each bedroom's location. A plan was also created showing each the total layout of the home. The letter was resent to the fire Marshall 2/11/26.
There is no other violation
· Target dates:1/30/26
· Specific dates:2/11/26
2. A plan to prevent future occurrences
· By ensuring that all letters have required information and descriptions on it |
02/11/2026
| Implemented |
| 6400.112(c) | There was no discussion on the fire drill record of any problems encountered during the fire drills for any of the homes reviewed. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | a. WHO: Administrative Staff
b. WHAT: There was no discussion on the fire drill record of any problems encountered during the fire drills for any of the homes reviewed.
c. WHEN and HOW
· Fire drill form was corrected with the details required discussion/note section on it
All individuals' fire drill forms have been updated.
· Target dates:1/22/26
· Specific dates:1/22/26
2. A plan to prevent future occurrences
· By ensuring that fire drills form contain a standardized log to promptly document the date, time, evacuation duration, exit routes, issues encountered, and alarm operability. |
01/22/2026
| Implemented |
| 6400.112(e) | There were sleeping hours drills done from 12/12/24 through 11/2025 for individual 1. | A fire drill shall be held during sleeping hours at least every 6 months. | a. WHO: Administrative Staff
b. WHAT: A fire drill shall be held during sleeping hours at least every 6 months.
c. WHEN and HOW
· Fire drill form was corrected with the details required Sleep/Awake options on it
There is no other violation
· Target dates:1/22/26
· Specific dates:1/22/26
2. A plan to prevent future occurrences
· Ensuring that future version of our fire drill record tracks sleep or awake option. |
01/22/2026
| Implemented |