| 6400.72(a) | On 11/25/2025 at 10:43 AM, the screen in the only window in Individual #1's bedroom was an accordion-style screen that did not provide a secure seal to prevent against infestation. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The Facilities Director was retrained on the regulation and that accordion style screens are not permitted. The screen was replaced on 11/25/25. |
11/25/2025
| Implemented |
| 6400.112(c) | The fire drill conducted at this residence on 12/20/2024 did not indicate if it was conducted at 7:15 AM or 7:15 PM. The agency's fire drill form has a section for staff to indicate if the drill was conducted ante meridiem or post meridiem; however, 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 Director, Program Specialist, Quality Assurance Associate, and Program Managers were retrained on the regulation. |
12/12/2025
| Implemented |