| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessments-were not completed prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| -Retraining on Regulation to Provider Admin staff by Compliance Manager
-Self Assessments are being completed by March 2022(due date for Provider) |
12/20/2021
| Implemented |
| 6400.67(a) | Missing ceiling tiles in multiple areas of the basement not in good repair exposed wires- could pose potential hazard-work orders requested, not provided. | Floors, walls, ceilings and other surfaces shall be in good repair. | -Ceiling was repaired by Provider (JDB Services)
-Wires were hidden to avoid potential Hazard (JDB Services) |
12/27/2021
| Implemented |
| 6400.82(e) | No non-slip surface or mat in the bathroom shower at inspection. | Bathtubs and showers shall have a nonslip surface or mat. | -Bathmat was Purchased by Community Home Manager and placed in the CLA bathroom bathtub |
12/27/2021
| Implemented |
| 6400.82(f) | The soap was locked in the bathroom closet not easily accessible to anyone using the bathroom without having keys to unlock the closet at each use. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | -Soap Was Made Accessible by Community Home Manager. Soap does not contain poisonous and is in original container. |
12/27/2021
| Implemented |
| 6400.112(c) | The fire drill dated 7/8/21 did not indicate whether the fire alarm or smoke detector was operative-all were left blank on the record provided. | 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. | -Unannounced Fire Drill Ran for the Month of December 2021 by DSP Staff with Community Home Manager Supervision that indicted whether the fire alarm and or smoke detector was operative and was not left blank on the record. |
12/27/2021
| Implemented |