| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual #1 had one pillow on their bed that was soiled. The pillow as observed with a dark yellow stain that covered approximately two thirds of the width of the pillow. According to Individual #1, the stain was caused by a leak in the roof that happened months prior. Individual #1 reported that the water leak landed on their pillow, causing the stain. | Clean and sanitary conditions shall be maintained in the home. | The program specialist took two pillows to the individual immediately on 8/7/2024. |
08/07/2024
| Not Implemented |
| 6400.66 | The exit located on the right side of the home did not have a light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance installed a light on the outside of the basement door on 8/15/2024 |
08/15/2024
| Implemented |
| 6400.67(a) | The ceiling tiles in the living room of the home had water damage from the roof leak that occurred months prior. The ceiling was observed with a light brown stain that measured approximately three feet by two feet. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance replaced the ceiling tiles on 8/21/2024 |
08/21/2024
| Implemented |
| 6400.80(b) | There were multiple cigarette butts located in the back yard around the premises of the side exit of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Management cleaned the cigarette butts up immediately on 8/7/2024 |
08/07/2024
| Implemented |
| 6400.81(k)(2) | Individual #1's mattress was placed directly on the floor and did not have a solid foundation. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Maintenance has a bed frame and box spring stored and is available immediately if individual wants it 08/08/2024 |
08/08/2024
| Implemented |
| 6400.81(k)(3) | Individual #1 had one pillow on their bed and it did not have a pillowcase. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | DSP put a pillowcase on both pillows on 8/07/2024 |
08/07/2024
| Not Implemented |
| 6400.101 | The cold seller in the basement of the home had a latch lock located on the left side of the door, preventing someone to exit if they were in the cold cellar and the latch lock was engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Maintenance removed lock on the door on 8/7/2024 |
08/07/2024
| Implemented |
| 6400.112(c) | The fire drill record for the drill completed on 4/11/2024 did not include the amount of time it took for evacuation. This section was left blank. | 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. | The program specialist will correct the issue by making sure all future fire drills are completely filled out before filing 8/23/2024 |
08/23/2024
| Implemented |
| 6400.171 | At 10:50 AM, there were Marketside Baby-Cut Carrots with an expiration date of 6/30/2024 in the bottom container of the refrigerator. At 10:54 AM, there were two pieces of fried chicken in the microwave. According to staff, it had been there for at least 30 minutes. It was not protected from contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Management threw away the bag of carrots on 8/7/2024 |
08/07/2024
| Implemented |
| 6400.163(d) | Individual #2 had an Albuterol Sulfate inhaler in their bedroom that was in an unlocked plastic container next to their desk. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Management locked up the albuterol inhaler immediately on 8/07/2024 |
08/07/2024
| Implemented |