| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | A container of antibacterial wipes was unlocked in the kitchen. | 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 |
| 6400.66 | Inoperable lights on the back porch. | 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 inoperable lights on the back porch. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.67(a) | The bathtub had cracked and discolored caulking and there was rusting of and around the drain. throughout the home there were parts of the wall that were spackled and not painted over. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to fix the caulking on the bathtub and the spackling on the walls. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.72(b) | The first-floor bathroom window screen was torn. | Screens, windows and doors shall be in good repair. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the window screen in the first-floor bathroom. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.80(a) | Snow was not removed outside of the back door. The snow was shoveled during the inspection. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | As noted in the deficiency, staff removed snow from the back door upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.110(e) | The fire alarm system was inoperable. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to add a nonslip surface to the shower stall in the primary bathroom. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.32(h) | There were no window coverings for two of Individual One's windows. | An individual has the right to privacy of person and possessions. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to add window coverings to the two windows. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |