| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | At 10:57 AM on 6/18/2024, the two outward opening windows near the closet in the kitchen of the home did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screens will be purchased or custom made by Maintenance Department to fit the windows at John St kitchen by July 31, 2024.
Responsible Party: Maintenance Director #4 |
07/31/2024
| Implemented |
| 6400.101 | At 11:00AM on 6/18/2024, the interior kitchen door leading to the basement had a sliding latch lock on the upper right corner posing an obstruced egress when engaged. At 11:05AM on 6/18/2024, the interior basement door of a storage room leading to the exterior door had a sliding latch lock approximately two inches above its doorknob assembly posing an obstruced egress when engaged. At 11:07AM on 6/18/2024, the basement's only exterior door leading to the outside had a sliding latch lock approximately six inches above its doorknob assembly posing an obstruced egress when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The lock was removed on 6/18/24.
Responsible Party:, Maintenance Director #4 |
06/18/2024
| Implemented |
| 6400.105 | At 11:04 AM on 6/18/24, a pinkish-colored thick layer of lint and dust particles was covering more than half of the clothes dryer lint filter. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The lint was immediately removed from the dryer vent on 6/18/24.
Responsible Party: Site Supervisor #7 at the site during inspection. |
06/18/2024
| Implemented |
| 6400.106 | The home's furnace was cleaned and inspected on 9/27/2022 and 9/27/2023 by an agency employee and not by a professional furnace cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| CLC will schedule furnace cleaning and inspection with Goods Heating for each site to be completed by September 30, 2024. We will obtain an invoice for each site that specifies the date and that cleaning and inspection was the service provided.
Persons Responsible: Maintenance Director #4 |
09/30/2024
| Implemented |
| 6400.112(a) | An unannounced fire drill was not held in December 2023. | An unannounced fire drill shall be held at least once a month. | There was no way to correct this violation from December. All sites with the exception of Fulton, Vermont, Unity, Frank and Dell Way did not have a December fire drill ran. |
07/01/2024
| Implemented |
| 6400.216(a) | At 11:01 AM on 6/18/2024, among boxes and stacks of documents, Individual #1's records entitled, "EL's Pill Counts for May 2004/June 2004," and a red binder labeled, "EL Med. Log." were unlocked in the storage room in the basement of the home. | An individual's records shall be kept locked when unattended.
| On 7/3/2024 the records were removed from John St and sent to the administrative office where they will remain locked until sent to shredding facility.
Responsible Party: CAO #6 |
07/03/2024
| Implemented |