| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There were shower shoes at the top second step of the basement stairs. They were removed during the time of inspection. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Staff immediately removed show shoes from the step upon discovery during the audit.
By 4/15/26, the Director of Program will hold a training with all staff to review results of the inspection, placing specific emphasis on all citations related to physical site, safety, and client rights requirements throughout the home. This meeting will be documented on a training sheet. |
04/30/2026
| Implemented |
| 6400.68(b) | The water for the kitchen sink measured 126.8 degrees Fahrenheit. The water in the half bathroom measured 129 degrees Fahrenheit. The water in the upstairs bathroom measured 127.4 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Program leadership immediately submitted maintenance requests to Merakey's facilities Department the day of the audit to lower the water temperature. |
02/25/2026
| Implemented |
| 6400.76(c) | The kitchen stove was missing a control knob. | Furniture shall be comfortable and home-like. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the control knob on the kitchen stove. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.106 | Annual Furnace Inspection for the home was not provided. | 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.
| The Director of Programs is actively collaborating with Merakey's real estate team and safety team to have the furnaces at each cited home reinspected as soon as possible. Copies of each inspection will be maintained in the Fire Safety Binder by the Director of Programs. |
04/30/2026
| Implemented |
| 6400.32(t) | The kitchen freezer has a lock on it. | An individual has the right to access food at any time. | A maintenance request was immediately placed to Merakey's facilities Department the week of the audit to unlock the kitchen freezer. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |