| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | On 1/8/2026 at 10:16AM, an unlabeled, plastic spray bottle with an unknown yellow substance was in the cabinet under the sink in the kitchen of the home. | Poisonous materials shall be stored in their original, labeled containers. | The cleaning products in the unlabeled containers mentioned above were discarded on 01/08/2026 by house residential staff.
An audit was conducted on 01/09/2026 by the Program Supervisor to ensure that all poisonous materials are stored in their original labeled containers with no additional findings.
· Current staff will be educated by Program Supervisor on Regulation Code 62(c) Poisonous materials shall be stored in their original product manufacturer's labeled containers at the monthly staff house meeting on 1/22/26.
· The monthly house inspection audit completed by the Program Supervisor has been updated to review poisonous materials monthly to ensure they continue to be stored in their original, labelled containers. |
01/08/2026
| Implemented |
| 6400.65 | On 1/8/2026 at 10:31AM, there was approximately a one-quarter-inch thick layer of dust on the cover of the mechanical ventilation fan on the ceiling, next to the bathtub in the bathroom in the hallway on the first floor of the home. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| - On 1/8/2026, the Program Supervisor reported to the 269 Vogel Road House and removed the thick layer of dust from the ventilation fan that was noted above (first floor bathroom fan) to bring the site into compliance with Code 65. The Program Supervisor removed the fan cover and vacuumed any remnants of thick collected dust and also cleaned the fan cover and blades with all-purpose cleaning solvent.
- On 1/12/2026 an in-service meeting was held at the program office. The Residential Director and CEO facilitated the meeting and reviewed Code 65 specifically with all Program Supervisors and Program Coordinators. A monthly cleaning checklist was introduced to the Vogel Home to ensure Code 65 was addressed consistently. Direct Care staff will be responsible for completing and verifying the Vogel house will be Code 65 compliant. The assigned Program Supervisor will verify compliance through reviewing the monthly cleaning checklist and conducting their monthly compliance checklist as well. The Residential Director will review both items to ensure completion and compliance to Code 65. |
01/22/2026
| Implemented |
| 6400.72(b) | On 1/8/2026 at 10:51AM, there was tear across the bottom of screen on the top half of the storm door at the front entrance of the home. | Screens, windows and doors shall be in good repair. | - On 1/8/26, Residential Director contacted Maintenance Manager to repair/ replace the torn front door screen at the 269 Vogel residence. Maintenance Manager reported to the Vogel home, and repaired the tear with screen tape and recommended complete replacement for longevity.
- On 1/16/26, Maintenance Manager reported to the Vogel home and replaced the noted screen (front door) and the home was now complaint for Code 72(b). |
01/16/2026
| Implemented |
| 6400.216(a) | On 1/8/2026 at 10:42AM, a binder containing Individual #1's service plan, assessment and binders containing Individual #1's, #2's and #3's personal identifiable information including, but not limited to, social security numbers, lifetime medical history, physical examinations and behavior support documents were unlocked and unattended on a shelf of the staff desk in the kitchen of the home. | An individual's records shall be kept locked when unattended.
| -On 1/8/2026, the assigned Program Supervisor reported to the 269 Vogel Road home and verified all materials and binders including personal identifiable information was locked and secured.
- On 1/12/2026 an in-service was held at the program office. Code 216(a) was reviewed with all attendees which were the Program Supervisors and Program Coordinators of the agency. All attendees signed and agreed to be vigilant of Code 216(a) at all agency homes and ensure all homes are compliant. The Program Supervisors will be responsible to complete the monthly compliance checklist at their assigned homes, which includes verification of compliance for Code 216(a).
- On 1/22/26, a mandatory house meeting is scheduled for all assigned staff at the 269 Vogel Road home. The Program Supervisor will facilitate the house meeting and will review Code 216(a) with all assigned house staff. Staff will sign attendance sheet of house meeting and verify knowledge and adherence to Code 216(a) at all times while they are working at the 269 Vogel home and all other agency homes. |
01/22/2026
| Implemented |