| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | On 2/11/2026, the storage room in the garage had carpet tacking strip with exposed nails around the entire perimeter of the room. | Floors, walls, ceilings and other surfaces shall be free of hazards. | February 13, 2026- The Maintenance Director completed repairs to the identified area of damage in the the garage, removing the exposed tacking strip and painting the floor. |
02/24/2025
| Implemented |
| 6400.68(b) | On 2/11/2026 at 12:35pm, the hot water temperature measured 131.3 degrees Fahrenheit at the bathtub in the hallway bathroom. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | February 11, 2026, The Maintenance Director turned the main water supply to the residence temporarily off and all faucets were fully drained. The hot water heater was adjusted and reset to 120°F. Water service was then restored to the home. Temperature readings were taken at all faucets throughout the residence. The water temperature did not exceed 120°F at any faucet at the time of testing. |
02/11/2026
| Implemented |
| 6400.111(f) | On 2/11/2026, the fire extinguisher in the attic of the home was last inspected and approved by a fire safety expert in January 2020. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | February 11, 2026 -The Maintenance Director replaced the expired fire extinguisher with an approved and properly inspected fire extinguisher to ensure continued compliance with fire safety regulations. |
02/11/2026
| Implemented |
| 6400.112(c) | The written fire drill records for the monthly fire drills held on 1/5/25, 4/2/25, 4/29/25, 6/9/25, 8/11/25, 11/13/25, 1/12/26 did not address problems encountered. | 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. | February 13, 2026 -- The Residential Director updated the Monthly Fire Drill Report form to ensure all required elements are answered directly and not left open-ended. The revised form now includes "Yes" or "No" response fields, with a required explanation of any problems encountered during the drill. |
02/23/2026
| Implemented |
| 6400.181(d) | The assessments dated 6/10/2025 and 6/8/2024 for Individual #1 were not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | February 13, 2026- Program Specialist #1 signed assessment completed on 6/8/2025 and 6/10/2025 |
02/13/2026
| Implemented |
| 6400.182(c) | The assessment dated 6/10/2025 for Individual #1 states heavy physical guidance, verbal prompting, or other measures of support are needed to temper water, however the individual plan that was last updated on 1/22/2026 states the individual can temper water and understands that hot water will burn you.
The assessment dated 6/10/2025 for Individual #1 states minimal support, verbal prompting, gestures, reminders, etc. to avoid poisonous/hazardous materials however the individual plan that was last updated on 1/22/2026 states the individual is aware of the dangers associated with poisonous substances and is not at risk for ingesting chemicals. The assessment dated 6/10/2025 for Individual #1 states minimal support, verbal prompting, gestures, reminders, etc. to move cautiously under hazardous conditions (including heat sources, water hazards) however the individual plan that was last updated on 1/22/2026 states the individual is aware of the dangers associated with heat sources. The assessment dated 6/10/2025 for Individual #1 states the individual is independent and needs no assistance evacuating during a fire; however the individual plan that was last updated on 1/22/2026 states the individual needs verbal prompting to evacuate. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | February 24, 2026 -The assessment was reviewed and revised to ensure full alignment with the current ISP. The updated assessment now accurately reflects the individual's current needs, supports, risk factors, and services. Documentation has been corrected, copies sent to supports coordinator and individual and placed in the individual record. |
02/26/2026
| Implemented |