| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | 67b: The light fixture in the ceiling located in the basement did not contain a cover, and the hole exposed rusty metal around/near the lightbulb in the light fixture and was rough/jagged when touched. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The area was cleaned and a cover was installed over the lightbulb. |
07/09/2026
| Implemented |
| 6400.101 | 101: The basement door of the home is equipped with a sliding deadbolt mechanism posing an obstructed egress from the basement when engaged. The sliding deadbolt was engaged at the time of the inspection | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The dead bolt was removed from the door. |
07/09/2026
| Implemented |
| 6400.143(a) | 143a: Individual #1 had a dental appointment on 4/14/26, and the agency "doctor phone consult" form noted under the presenting problem section of the form "Individual #1 refused his dental apt, he would not get out of the van." There was no record or documentation provided to the Licensing Representative (LR) that in Individual #1 was trained on 4/14/26 on the importance of dental appointments/dental hygiene. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 is on an on-going dental desensitization plan where he participates in desensitization training monthly. This was attached to his refusal documentation. Documentation of this will also be sent to Kristen Salus. |
07/09/2026
| Implemented |
| 6400.213(1)(i) | Actual violation is 213(1)(iv): Religion was left blank on the individual profile section of Individual #1's record. 213(1)(iv) was not an option in the drop-down items in CLS. 213(1)(iv) is the violation cited and to be addressed. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual's religion was added to his individual profile. |
07/09/2026
| Implemented |