Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283751 Renewal 02/24/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The supply closet containing chemicals was observed unlocked. This was corrected during the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. 04/30/2026 Implemented
6400.62(c)A reused water bottle was observed under the kitchen sink and labeled bleach.Poisonous materials shall be stored in their original, labeled containers. All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. 04/30/2026 Implemented
6400.64(b)Rodent droppings were observed in the kitchen cabinet above the stovetop microwave.There may not be evidence of infestation of insects or rodents in the home. Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to have an external exterminator company review the home for any potential infestations of insects or rodents. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented
6400.66The garage's exterior light fixture had a bulb that did not light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to fix the garage's exterior light fixture. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented
6400.68(c)Since the Agency's July 2025 acquisition of new properties, actual E Coliform test results were reviewed for July 22,2025 and October 21, 2025. Email correspondence reviewed was dated February 24, 2026, at 4:10pm that acknowledged a "coliform bacteria water sample was picked up today. We will email test results as soon as they are received." However, the required 3-month timeline was missed by one month as the next test should have been in January 2026.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.The water was tested at the home by SPEL on 2/24/2026. Please see attached testing results showing the home passed. 02/24/2026 Implemented
6400.72(a)The garage window had a broken window. A leak was observed from a gasket under the kitchen sink.Windows, including windows in doors, shall be securely screened when windows or doors are open. Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the broken window in the garage. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented
6400.1042025 notification to fire department letter was not provided.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Notification for Pinecroft was provided to the local fire department on 7/1/25. An updated copy was mailed out immediately after the audit. 04/30/2026 Implemented
6400.106Annual 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
6400.46(d)Staff One's CPR/First Aide training expired on 2.8.26Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #1 completed CPR training in Merakey's learning management system (LMS) on 2/18/26 and will be scheduled for skills training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation (CPR) training when they return from leave. The updated certificate will be provided to program leadership and sent to HR to keep in their employee file. 04/30/2026 Implemented
6400.52(c)(3)There was no record to show that Staff One received Individual Rights training during the review period.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 will complete Individual Rights training in Merakey's LMS when they return from leave. The updated certificate will be provided to program leadership and sent to HR to keep in their employee file. 04/30/2026 Implemented
6400.162(b)(1)Training Logs for Staff Two indicated they attended medication administration training; however, training records and practicums were not available for review.A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications.Staff 2 is no longer able to administer medication and will be rescheduled for Medication Administration training, which includes completed medication pass observations. 04/30/2026 Implemented