Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | Surfaces were not in good repair. The sliding closet doors of the medication closet were broken. Both doors were off of the track and difficult to open and close. | Floors, walls, ceilings and other surfaces shall be in good repair. | Residential Director, Christine Byard coordinated with the maintenance staff to remove the faulty doors and use am interior shelving system. Please see the documents with images sending via email. |
03/15/2025
| Implemented |
6400.111(f) | The fire extinguisher located in the basement of the home was not inspected annually. The tag indicated that the last inspection was January 2024. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Residential Director, Christina Byard coordinated with Residential Director, Frank Kibaara to have a properly inspected Fire Extinguisher brought to the home within an hour of the time of the inspection. Please see the document with image sending via email. |
03/04/2025
| Implemented |
6400.171 | Food is not properly stored from contamination. There was an ice cream cone with ice cream in it stored in the freezer without any covering or protection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Residential Director, Christina Byard, corrected at the time of the inspection that a DSP had placed the Ice Cream Cone in the freezer unwrapped, educating the DSP in the process. |
03/04/2025
| Implemented |
6400.163(d) | The medication closet was not locked at the time of the inspection. There were two locks on the closet and both were unlocked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Residential Director, Christina Byard, corrected the unlocked medication situation at the time of inspection. Later the Medication storage unit was installed. Please see the document image sending via email. |
03/08/2025
| Implemented |