| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | (Repeat from 5/1/23 Inspection) At the time of the inspection, the water temperature in the sinks measured at 127 and 127.2. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The Residential Director and Residential Coordinator were trained on 5/15/2024 on Regulation 6400.63(a) by Director of Quality Assurance, see Attachment #130. The Director of Quality Assurance developed a maintenance request form on 5/1/2024 to be used for reporting and tracking progress for all maintenance needs of the home. The new maintenance request form was completed for the water temp and submitted to the CEO on 5/3/2024 as attachment # 131. The CEO has contacted the property owner via email on 5/6/2024 and requested for the water temp to be turned down as attachment # 132. Director of Quality assurance will check the water temp no later than 5/25/2024 in the sinks, will send picture as Attachment #134 |
05/25/2024
| Implemented |
| 6400.68(b) | At the time of the inspection, the water temperature in the tub measured at 125.9. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Residential Director and Residential Coordinator were trained on 5/15/2024 on Regulation 6400.68(b) by Director of Quality Assurance, see Attachment #135. The Director of Quality Assurance developed a maintenance request form on 5/1/2024 to be used for reporting and tracking progress for all maintenance needs of the home. The new maintenance request form was completed for the water temp and submitted to the CEO on 5/3/2024 as attachment # 131. The CEO has contacted the landlord via email on 5/6/2024 and requested for the water temp to be turned down as attachment # 132. Director of Quality assurance will check the water temp no later than 5/25/2024 in the bathtub, will send picture as Attachment #136 |
05/25/2024
| Implemented |
| 6400.70 | At the time of the inspection, there was not an operable phone in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Comcast installed a phone line on 5/13/2024, copy of email of installation date as Attachment #137. Picture of phone in the home along with emergency numbers sent as attachment # 138. Residential Program Specialist, Residential Director and Residential Coordinator were trained on Regulation 6400.70 on 5/15/2024 and 5/17/2024by Director of Quality Assurance, see attachment #139. |
05/17/2024
| Implemented |
| 6400.73(a) | At the time of the inspection, there was a flight of stairs leading up towards the house, that do not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Handrails were installed on 5/13/2024, a picture is sent as Attachment #140. Residential Program Specialist, Residential Director and Residential Coordinator were trained on Regulation 6400.73(a) on 5/15/2024 and 5/17/2024by Director of Quality Assurance, see attachment #141. |
05/17/2024
| Implemented |
| 6400.77(a) | At the time of the inspection, there was no first aid kit in the home. | A home shall have a first aid kit. | First aid kit was purchased for the home on 5/1/2024 and a picture showing the first aid and contents is sent at Attachment #142. Residential Program Specialist, Residential Director and Residential Coordinator were trained on Regulation 6400.77(a) on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see attachment #143. |
05/17/2024
| Implemented |
| 6400.80(a) | At the time of the inspection, there was no walkway between the flight of stairs leading to the property and the flight of stairs leading directly to the porch. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The Residential Director, Residential Program Specialist and Residential Coordinator were trained on 5/15/2024 and 5/17/2024 on Regulation 6400.80(a) by Director of Quality Assurance, see Attachment #144. The Director of Quality Assurance developed a maintenance request form on 5/1/2024 to be used for reporting and tracking progress for all maintenance needs of the home. The new maintenance request form was completed for the need of a walkway in the front of the home and submitted to the CEO on 5/3/2024 as attachment # 145. The CEO has contacted the property owner via email on 5/06/2024 and requested for the need of a walkway as attachment # 146. If the property owner does not complete the work by 6/30/2024 then the agency put in a walkway. Once the work is completed, a picture will be taken of the work and sent in as attachment # 147. |
06/30/2024
| Implemented |
| 6400.106 | (Repeat from 5/1/23 Inspection) The home was opened on 4/2/24 and has a gas furnace. At the time of the inspection, there was no furnace inspection or cleaning completed. | 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 CEO received an email from the property owner on 4/30/2024 showing that a new hot water boiler/in floor heat system was placed in the home, see Attachment # 148. The property owner sent another email on 4/30/2024 verifying that the system was installed in February 2024, see attachment #149. |
05/20/2024
| Implemented |
| 6400.111(c) | At the time of the inspection, there were no fire extinguishers in the home. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire extinguishers were delivered to the home on 5/01/2024; see Invoice as Attachment # 151. Picture of the fire extinguishers in the home are sent as Attachment # 152. The Residential Director, Residential Program Specialist and Residential Coordinator were trained on 5/15/2024 on Regulation 6400.111(c) by Director of Quality Assurance, see Attachment #153 |
05/20/2024
| Implemented |
| 6400.111(f) | At the time of the inspection, there was no documentation verifying the fire extinguishers have been inspected in the past year or are newly purchased. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The Residential Director and Residential Coordinator were trained on Regulation 6400.111(f) on 5/15/2024 by the Director of Quality Assurance as Attachment # 154. |
05/20/2024
| Implemented |