| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(d) | On 4/3/2025 at approximately 12:25pm, Assistant Director #1 confirmed that the on-site kitchen is used weekly on Fridays for cooking activities and lessons. The on-site kitchen is not currently on the facility's license. The agency is conducting regularly scheduled programming activities in an unlicensed area. | The legal entity shall complete and submit a separate application for a certificate of compliance for each facility or agency subject to licensure or approval. | As per the interaction with licensing representative Rebecca MacDonald, provider will submit floor plans of the spaces to her and together we can work to get them added as inspections come up to ensure compliance in future inspections. Butler Day Program dimensions were taken on 4/3/25 to satisfy this. |
04/08/2025
| Implemented |
| 2380.61 | On 4/3/2025 at 12:40pm, the only phone that was available at the facility was observed in the Program Specialist office. The Program Specialist office contains the individual records and is locked if the office is not in use, making the telephone inaccessible to the individuals. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | On 4/3/2025 at approximately 12:41 PM, the phone was moved from the program specialist office to the licensed program area making it accessible for individuals to use. |
04/03/2025
| Implemented |
| 2380.71 | On 4/3/2025 at 12:20pm, it was observed that the certificate of operation issued by the Department of Labor and Industry for the building's elevator expired on 1/31/2025. | If an elevator is present in the facility, there shall be a valid certificate of operation from the Department of Labor and Industry. | On 4/7/2025 a request was submitted to the Department of Labor from the Trinity Lutheran church. The department answered stating that it was not due until 5/2025 as stated to inspector per the certificate on 4/3/25. A duplicate certificate was requested and will be mailed from the department at the end of April. Provider will not utilize the elevator until that permit has been received. |
04/08/2025
| Implemented |
| 2380.21(u) | Individual #1 was informed or their individual rights and the process to report a rights violation on 7/25/2023 and again or 7/26/2024. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | The Program Specialist was retrained on this regulation on 4/3/25. Additionally, the agency obtained compliant releases from the individual dated 4/4/25 to satisfy this requirement. |
04/04/2025
| Implemented |