Johnnie Maes

5180:2-13-18 Attendance

“During the inspection, it was determined the program did not meet the requirements for keeping an attendance record as listed in numbers 2, 7, and 8 below:1. No attendance record was being maintained.2. The attendance record was not being consistently completed.3.The record did not include the name of at least one child.4. The record did not include the birth date of at least one child.5.The record did not include the assigned group.6.The record did not include the childs weekly schedule.7.The record did not include the time (hours and minutes) of each childs arrival and departure to the program, including transportation by the program.8. The original attendance record was not kept at the program for a period of one year.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-15 Child Medical and Enrollment Records

“In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in numbers 4, 6, 13, 14, and 16 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other: date when parent and administrator signed enrollment was missing.Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-09 Background Checks (closed - not addressed)

“In review of the staff records, it was determined that background checks did not meet the requirements of the rule for the person(s) listed on the Employee Record Chart as noted in numbers 1, 2, and 4 below:1. The request for a background check for child care was not submitted in the OPR.2. The fingerprints were not submitted electronically according to the process established by BCI.3. The individual(s) had engaged in assigned duties or were near children and preliminary approval from ODJFS was not on file.4. Background checks were not updated every five years. Submit the programs corrective action plan, which includes a copy of the JFS 01176, or a copy of the preliminary approval or a statement that the individual(s) are no longer engaged in assigned duties and are not near children until the preliminary approval has been received, to the Department to verify compliance with the requirements of this rule.”

5180:2-13-15 Child Medical and Enrollment Records

“In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in numbers 12, 13, and 14 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other [ ] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-10 Health Training

“In review of records, it was determined the CCSM or Substitute CCSM was left alone with children and did not have current valid documentation for training(s) listed in number 14 below:1. First Aid - expired training2. First Aid - did not have verification of completion of First Aid training3. First Aid - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule 4. CPR - expired training5. CPR - had not taken CPR training6. CPR - did not have verification of the completion of CPR training7. CPR - training taken did not include all age groups the program serves and developmental levels of all children in care8. CPR - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule9. CPR - audiovisual or electronic media training taken by staff did not include an in-person component of the training 10. Communicable Disease - expired training11. Communicable Disease - had not taken CD training12. Communicable Disease - did not have verification of the completion of the CD training13. Communicable Disease - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule14. Child Abuse - expired training15. Child Abuse - had not taken Child Abuse training16. Child Abuse - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the ruleCorrect the violation and submit the documentation of current certification with the program's corrective action plan to verify compliance with the requirement of the rule.”

5180:2-13-10 Professional Development

“In review of records, it was determined the Child Care Staff Member(s) indicated on the Employee Record Chart did not meet the annual professional development requirement as noted in number 11. The child care staff member(s) had not completed at least six hours of professional development.2. Documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule. 3. Training topic did not meet the requirements listed in appendix A of this rule. 4. Documentation of training did not meet the requirements of this rule. 5. The substitute(s) had been used more than ninety days annually between July first and June thirtieth and had not completed at least six hours of professional development.6. Other [ ].Submit the programs corrective action plan to verify compliance with the requirements of this rule.”

5180:2-13-08 Child Care Staff Requirements

“In review of the staff records, it was determined that child care staff member(s) or substitute child care staff member(s) did not meet the requirements for completing the online orientation training as noted in number 1 below:1. The training was not completed within 30 days of starting employment at the program as a child care staff member.2. No documentation of completing the training after December 31, 2016.3. Completion of the training was not verified in the OPR.4. A child care staff member had sole responsibility of children and had not completed the online orientation.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-03 Inspection Requirements

“During the inspection, it was determined the program had not responded to the non-compliances addressed in the inspection report dated 4/24/2025. The rule requires the program complete and submit a corrective action plan in OCLQS to address non-compliances detailed in written inspection reports within the timeframe outlined in the report. Submit the programs corrective action plan, which includes a statement that current and future corrective action plans will be submitted timely, to the Department to verify compliance with the requirements of this rule.”

5180:2-13-12 Safe Environment

“Children in care shall be protected from any items and conditions which threaten their health, safety, and well being. During the inspection, it was determined that children were not protected from the following item(s) or condition(s) which may threaten their health, safety, or well being as noted in the following number 1 below:1. Surge protectors/outlets did not have childproof receptacle covers.2. Open pull cords that are not closed loop.3. Toys or other items small enough to be swallowed were present in the space where infants and/or toddlers were in care.4. Electrical/extension cords attached to an object that would not likely result in a severe injury if pulled.5. Stacked chairs.6. Telephone cords.7. Employee(s) purse(s).8. Diaper bags.9. Television not securely anchored.10. Small or lightweight pieces of shelving units are not securely anchored to the wall.11. Staff member stepped over a barrier/gate while holding a child.12. Chipping or peeling paint.13. An area rug did not have a nonskid backing.14. An area rug presented a tripping hazard.15. A floor surface was unsafe in that [ ].16. No platform was provided for the sink or toilet.17. The platform provided for the sink or toilet was not sturdy.18. The platform provided for the sink or toilet posed a safety hazard in that [ ].19. Emergency exits were blocked by the following furniture in that [ ].20. A mercury thermometer was being used to take a childs temperature. 21. Methods of ventilation used did not provide protection from rodents, insects, or other hazards.22. Other [ ].Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-10 Health Training (closed - not addressed)

“In review of records, it was determined the provider did not have current valid documentation for training(s) listed in numbers 1 and 4 below:1. First Aid - expired training2. First Aid - did not have verification of the completion of First Aid training3. First Aid - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule4. CPR - expired training5. CPR - had not taken CPR training6. CPR - did not have verification of the completion of CPR training7. CPR - training taken did not include all age groups and developmental levels of all children in care8. CPR - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule9. CPR- audiovisual or electronic media training taken did not include an in-person component of the training10. Communicable Disease - expired training11. Communicable Disease - had not taken CD training12. Communicable Disease - did not have verification of the completion of CD training13. Communicable Disease - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule 14. Child Abuse - expired training15. Child Abuse - had not taken Child Abuse training16. Child Abuse - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the ruleCorrect the violation and submit the documentation of current certification with the program's corrective action plan to verify compliance with the requirement of the rule.”

5180:2-13-08 Child Care Staff Requirements (closed - not addressed)

“In review of the staff records, it was determined that child care staff members: Alanna Bradshaw and Cyara Turner did not meet the requirements for completing the online orientation training as noted in number 1 below:1. The training was not completed within 30 days of starting employment at the program as a child care staff member.2. No documentation of completing the training after December 31, 2016.3. Completion of the training was not verified in the OPR.4. A child care staff member had sole responsibility of children and had not completed the online orientation.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-08 Child Care Staff Requirements (closed - not addressed)

“In review of the staff records, it was determined the training requirements were not met for the Child Care Staff Member [Cyara Turner] listed on the Employee Record Chart, as required. Submit the program's corrective action plan, which includes copies of verification of training, to verify compliance with the requirements of this rule.”

5180:2-13-04 Fire Inspections for Type A Homes (closed - not addressed)

“The program had not been inspected and approved within 12 months from the date of the last fire approval by the local fire department, as required. Secure and submit an updated fire approval as part of the programs corrective action plan to verify compliance with the requirement of the rule.”

5180:2-13-03 Inspection Requirements

“During the inspection, it was determined the program had not responded to the non-compliances addressed in the inspection report dated 10/31/2024 The rule requires the program complete and submit a corrective action plan in OCLQS to address non-compliances detailed in written inspection reports within the timeframe outlined in the report. Submit the programs corrective action plan, which includes a statement that current and future corrective action plans will be submitted timely, to the Department to verify compliance with the requirements of this rule.”

5180:2-13-14 Vehicle Requirements

“During the inspection, it was determined the vehicle utilized by the program does not meet the requirements for transporting children in care in that no vehicle inspections logs were being kept for vehicles being used. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.”

5180:2-13-14 Driver Requirements

“During the inspection, it was determined that the requirements for drivers was not met as listed in number 1 below:1. The driver(s) noted on the Employee Record Chart used for trips did not have a copy of a current driver's license on file.2. At least one employee or child care staff member who is responsible for transporting children did not have documentation of completion of the prescribed driver training on file.3. The driver used to transport children was not an employee or child care staff member of the program, a public transportation driver, or employed by a company contracted to provide transportation service.4. The driver who was not a child care staff member or employee who is used in accordance with the requirements in rule 5101:2-13-08 transported children without the provider present.Remove this individual from transporting children until the requirements are met. Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5180:2-13-09 Background Checks

“In review of the staff records, it was determined that background checks did not meet the requirements of the rule for the person(s) listed on the Employee Record Chart as noted in number 1 below:1. The request for a background check for child care was not submitted in the OPR.2. The fingerprints were not submitted electronically according to the process established by BCI.3. The individual(s) had engaged in assigned duties or were near children and preliminary approval from ODJFS was not on file.4. Background checks were not updated every five years. Submit the programs corrective action plan, which includes a copy of the JFS 01176, or a copy of the preliminary approval or a statement that the individual(s) are no longer engaged in assigned duties and are not near children until the preliminary approval has been received, to the Department to verify compliance with the requirements of this rule.”

5180:2-13-07 Staff Records

“During the inspection, it was determined that employment records in the Ohio Professional Registry (OPR) were not created or maintained as noted in number 6 below: 1. The provider had not created or updated their individual profile in the OPR.2. The provider had not created or updated the program's organizational dashboard in the OPR.3. At least one employee, child care staff member, or substitute child care staff member had not created or updated their individual profile in the OPR. 4. At least one employee, child care staff member, or substitute child care staff member had not created an employment record in the OPR for the program on or before the first day of employment, including date of hire.5. At least one employee, child care staff member, or substitute child care staff member had not updated changes to positions or roles in the OPR within five calendar days of the change.6. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's scheduled days and hours changed.7. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's group assignments changed, if applicable.8. The program's organizational dashboard in the OPR was not updated with the employment end date within five business days when at least one employee, child care staff member, or substitute child care staff member ended employment.9. At least one resident over the age of eighteen had not created a profile and employment record for the family child care provider within five days of becoming a resident or turning eighteen.10. The program's organizational dashboard in the OPR was not updated within five calendar days of a change in residency for at least one resident over the age of eighteen.11.Other: [] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.”

5101:2-13-16 Emergency Preparedness and Response Plan (closed - not addressed)

“During the inspection, it was determined the programs written emergency preparedness and response plan did not meet the requirement or was missing the information in number 1/18 below:Procedures:1. The written emergency and preparedness and response plan had not been completed2. The plan was not provided to all child care staff and employees3. Weather emergencies and natural disasters which include severe thunderstorms, tornadoes, flash flooding, major snowfall, blizzards, ice storms or earthquakes4. Emergency outdoor and indoor lockdown or evacuation due to threats of violence which includes active shooter, bioterrorism or terrorism including a designated safe site where staff and children can safely remain when evacuated5. Emergency or disaster evacuations due to hazardous materials and spills, gas leaks or bomb threats including a designated safe site where staff and children can safely remain when evacuated6. Outbreaks, epidemics or other infectious disease emergencies7. Loss of power, water, or heat8. Other threatening situations that may pose a health or safety hazard to the children in the programDetails:9. Shelter in place or evacuation, how the program will care for and account for the children until they can be reunited with the parent10. Assisting infants, toddlers and children with special needs and/or health conditions11. Emergency contact information for parents and the program12. Procedures for notifying and communicating with parents regarding the location of the children if evacuated13. Procedures for communicating with parents during loss of communications, no phone or internet service available14. The location of supplies and procedures for gathering necessary supplies for staff and children if required to shelter in place15. What to do if a disaster occurs during the transport of children or when on a field trip or routine trip16. Making the plan available to all child care staff members and employees17. Training of staff or reassignment of staff duties as appropriate18. Updating the plan on a yearly basis19. Contact with local emergency management officials20. The plan was unable to be implemented in that, [ ].Submit the programs corrective action plan, which includes the missing information, if applicable, to verify compliance with the requirements of this rule.”

5101:2-13-15 Child Medical and Enrollment Records

“In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in number 14 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other [ ] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.”

5101:2-13-15 Child Medical and Enrollment Records

“In review of of the children's records, it was determined that completed medical statements were not on file, as required, for children listed on the JFS Children's Record Review For Child Care as indicated in numbers 1 and 2 below:1. No medical was on file for at least one child 2. Medical(s) on file was not updated every 13 months 3. Medical(s) were missing child's name and date of birth4. Medical(s) were missing the date of the medical examination5. The date of the exam was more than 13 months prior to the date the form was signed 6. Medical(s) were missing a statement that the child has been examined and is in suitable condition for participation in group care7. Medical(s) were missing the signature, business address and telephone number of the physician, physician's assistant(PA), advance practice nurse (APN) or certified nurse practitioner (CNP) who examined the child8. Medical(s) were missing a record of immunizations the child has had specifying month, day and year9. Medical(s) were missing a statement from the physician, PA, APN, or CNP that the child has been immunized or is in the process of being immunized against the diseases required by division 5104.014 of the Revised Code and found in appendix A to this rule10. Medical(s) were missing a statement from the childs parent or guardian that he or she has declined to have the child immunized against the disease for reasons of conscience, including religious convictions11. Other [ ] Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule. .”

5101:2-13-12 Safe Environment

“Children in care shall be protected from any items and conditions which threaten their health, safety, and well being. During the inspection, it was determined that children were not protected from the following item(s) or condition(s) which may threaten their health, safety, or well being as noted in the following number 1 below:1. Surge protectors/outlets did not have childproof receptacle covers.2. Open pull cords that are not closed loop.3. Toys or other items small enough to be swallowed were present in the space where infants and/or toddlers were in care.4. Electrical/extension cords attached to an object that would not likely result in a severe injury if pulled.5. Stacked chairs.6. Telephone cords.7. Employee(s) purse(s).8. Diaper bags.9. Television not securely anchored.10. Small or lightweight pieces of shelving units are not securely anchored to the wall.11. Staff member stepped over a barrier/gate while holding a child.12. Chipping or peeling paint.13. An area rug did not have a nonskid backing.14. An area rug presented a tripping hazard.15. A floor surface was unsafe in that [ ].16. No platform was provided for the sink or toilet.17. The platform provided for the sink or toilet was not sturdy.18. The platform provided for the sink or toilet posed a safety hazard in that [ ].19. Emergency exits were blocked by the following furniture in that [ ].20. A mercury thermometer was being used to take a childs temperature. 21. Methods of ventilation used did not provide protection from rodents, insects, or other hazards.22. Other [ ].Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5101:2-13-10 Professional Development (closed - not addressed)

“In review of records, it was determined the Child Care Staff Member(s) indicated on the Employee Record Chart did not meet the annual professional development requirement as noted in number 1:1. The child care staff member(s) had not completed at least six hours of professional development.2. Documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule. 3. Training topic did not meet the requirements listed in appendix A of this rule. 4. Documentation of training did not meet the requirements of this rule. 5. The substitute(s) had been used more than ninety days annually between July first and June thirtieth and had not completed at least six hours of professional development.6. Other [ ].Submit the programs corrective action plan to verify compliance with the requirements of this rule.”

5101:2-13-08 Child Care Staff Requirements

“In review of the staff records, it was determined that child care staff member [Cyara Turner] or substitute child care staff member(s) did not meet the requirements for completing the online orientation training as noted in number 1 below:1. The training was not completed within 30 days of starting employment at the program as a child care staff member.2. No documentation of completing the training after December 31, 2016.3. Completion of the training was not verified in the OPR.4. A child care staff member had sole responsibility of children and had not completed the online orientation.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.”

5101:2-13 Written Policies and Procedures (closed - not addressed)

“On the day of the inspection, the programs written policies and procedures provided to the parents/guardians and employees was missing item number 15 below: General Information1. Name, address, email address and telephone number.2. Description of the providers program philosophy.3. Days and hours of operation, scheduled closings and basic daily schedule.4. Staff/child ratios and group size.5. Opportunities for parent involvement in activities.6. Opportunities for parents to meet with the provider regarding their child.7. Payment schedule, overtime charges and registration fees if applicable.8. Programs shall have a policy in place describing supports for onsite breastfeeding or pumping for mothers who wish to do so (if the program serves infants or toddlers). Provider Policies and Procedures9. Enrollment including required enrollment information.10. Care of children without immunizations.11. Attendance including procedures for arrival and departure, the program's absent day policy, releasing child to persons other than the parent, releasing a child according to a custody agreement and follow up when a child scheduled to arrive from another program or activity does not arrive.12. Supervision of children, including a separate supervision policy for school-age children, if applicable.13. Child guidance.14. Suspension and expulsion.15. Ensure compliance with the Americans and Disabilities (ADA) including administering medication to children with disabilities and administering care procedures for children with disabilities.16. Outdoor play, including limitations placed on outdoor play due to weather or safety issues (considerations may include but are not limited to temperature, humidity, wind chill, ozone levels, pollen count, lightning, rain or ice). 17. Food and dietary policy, including information regarding meeting one-third of the child's recommended daily dietary allowance, policy regarding formula, breast milk, meals, and snacks and policy on providing supplemental food. 18. Management of illness including isolation precautions, symptoms for discharge and return, notification of parent of ill child and whether or not the provider will care for sick children.19. Summary of procedures taken in the event of an emergency, serious illness or injury.20. Administration of medication and topical products policy, medical foods, modified diets, and whether school age children are permitted to carry their own medical and ointments.21. Transportation policy for field trips, routine walks, if applicable, and emergencies including if the provider will provide child care services to children whose parents refuse to grant consent for transportation to the source of emergency treatment.22. Water activities/swimming.23. Infant care, if applicable, including feeding, frequency of diaper checks, and information about daily activities.24. Sleeping, napping and resting.25. Evening and overnight care, if applicable.26. Policy on hours of operation, closing due to weather, school delays or closings and any other factors.27. Use of a substitute child care staff member or child care staff member pursuant to 5101:2-13-08 of the Administrative Code for sick days, vacations or other time off.28. Situations that may require disenrollment of a child, if applicable.29. Problem or issue resolution for parents or employees to follow when needing assistance in resolving problems related to the family child care home.30.Formal screenings and assessments conducted on enrolled children and if the program reports child level data to ODJFS pursuant to Chapter 5101:2-17 of the Administrative Code.Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.”

5101:2-13-15 Child Medical and Enrollment Records

“In review of of the children's records, it was determined that completed medical statements were not on file, as required, for children listed on the JFS Children's Record Review For Child Care as indicated in number 1 below:1. No medical was on file for at least one child 2. Medical(s) on file was not updated every 13 months 3. Medical(s) were missing child's name and date of birth4. Medical(s) were missing the date of the medical examination5. The date of the exam was more than 13 months prior to the date the form was signed 6. Medical(s) were missing a statement that the child has been examined and is in suitable condition for participation in group care7. Medical(s) were missing the signature, business address and telephone number of the physician, physician's assistant(PA), advance practice nurse (APN) or certified nurse practitioner (CNP) who examined the child8. Medical(s) were missing a record of immunizations the child has had specifying month, day and year9. Medical(s) were missing a statement from the physician, PA, APN, or CNP that the child has been immunized or is in the process of being immunized against the diseases required by division 5104.014 of the Revised Code and found in appendix A to this rule10. Medical(s) were missing a statement from the childs parent or guardian that he or she has declined to have the child immunized against the disease for reasons of conscience, including religious convictions11. Other [ ] Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule. .”

5101:2-13-10 Health Training

“In review of records, it was determined the CCSM or Substitute CCSM was left alone with children and did not have current valid documentation for training(s) listed in number 10 below:1. First Aid - expired training2. First Aid - did not have verification of completion of First Aid training3. First Aid - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule 4. CPR - expired training5. CPR - had not taken CPR training6. CPR - did not have verification of the completion of CPR training7. CPR - training taken did not include all age groups the program serves and developmental levels of all children in care8. CPR - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule9. CPR - audiovisual or electronic media training taken by staff did not include an in-person component of the training 10. Communicable Disease - expired training11. Communicable Disease - had not taken CD training12. Communicable Disease - did not have verification of the completion of the CD training13. Communicable Disease - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule14. Child Abuse - expired training15. Child Abuse - had not taken Child Abuse training16. Child Abuse - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the ruleCorrect the violation and submit the documentation of current certification with the program's corrective action plan to verify compliance with the requirement of the rule.”

5101:2-13-03 Inspection Requirements

“During the inspection, it was determined the program had not responded to the non-compliances addressed in the inspection report dated [ 8/2/2023 ]. The rule requires the program complete and submit a corrective action plan in OCLQS to address non-compliances detailed in written inspection reports within the timeframe outlined in the report. Submit the programs corrective action plan, which includes a statement that current and future corrective action plans will be submitted timely, to the Department to verify compliance with the requirements of this rule.”