| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | Individual #1's chair in the dining room was mising fabric and the cushion was exposed. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The dining room table and chairs have been replaced with a new set. See attached receipt. Moving forward, the home supervisor will complete a weekly home visit and check that all furniture and equipment will be clean, sturdy, and non hazaradous and document on the home visit report form. If something is not compliant with the regulation, the process to replace will begin immediately. |
02/14/2017
| Implemented |
| 6400.110(a) | There is no smoke dector in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The attic doorway has been screwed shut by the Shadowfax Maintenance staff as per ODP staff recommendations so it is no longer a habitable space. See attached picture. Moving forward, this will be checked on weekly house visits by management on home visits, to ensure there is a fire extinguisher on each floor of the home. See attached blank and completed form. |
12/22/2016
| Implemented |
| 6400.111(a) | There is no fire extinguisher in the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The attic doorway has been screwed shut by the Shadowfax Maintenance staff as per ODP staff recommendations so it is no longer a habitable space. See attached picture. Moving forward, this will be checked on weekly house visits by management on home visits, to ensure there is a fire extinguisher on each floor of the home |
12/22/2016
| Implemented |
| 6400.113(a) | The training on 11/22/16 did not have individual #2. It listed individual #3 who passed away on 4/16. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | CDI. When the new individual moved in, staff cut and pasted on the word document instead of typing the names after fire safety training was completed. By cutting and pasting, the individual that had passed away was still listed and the new individual that moved in was not listed. This was corrected immediately by Shadowfax management upon the discovery by ODP staff while on site during the inspection. See attached training sheet. In the future, the handwritten document showing the individual's signature will be maintained in the fire log and the person updating the training page in the fire log will manually type the persons name instead of cutting and pasting to ensure the correct/proper names appear in the log. |
11/30/2016
| Implemented |