Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266453 Renewal 05/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)There is an evident infestation of ants throughout the home with a heavy concentration in the kitchen area and cabinetry.There may not be evidence of infestation of insects or rodents in the home. On 6/23/2025, the agency contracted Alpha and Omega Pest Control, a licensed pest management company, to treat the entire residence due to a visible ant infestation, particularly concentrated in the kitchen area and cabinetry. The provider applied targeted pest control treatment in all affected areas, including interior baseboards, kitchen cabinets, and entry points. Since the initial treatment, there has been no visible evidence of ants or continued infestation in the residence. The pest control provider will continue to perform monthly pest control services to prevent recurrence. A copy of the pest control invoice and treatment plan is attached for verification. 06/23/2025 Implemented
6400.67(a)The following areas require repair or replacement: -The mini blinds in Individual #1's room. -The vent cover in the bathroom is rusted and hanging off.Floors, walls, ceilings and other surfaces shall be in good repair. New mini blinds were purchased and installed in Individual #1's bedroom on 6/23/2025. The damaged blinds were removed and properly disposed of. In addition, the rusted and loose bathroom vent cover was replaced with a new vent cover purchased from Home Depot and securely installed. Photos of the completed repairs available for verification. 06/23/2025 Implemented
6400.112(c)Fire drill completed in December 2024 does not indicate the length of the drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill conducted in December 2024 was completed; however, the staff inadvertently failed to record the evacuation duration on the fire drill form. Upon internal review, the Program Supervisor verified that the duration of the drill minutes had been documented in the shift notes on the day of the drill. As a corrective measure, the original fire drill form was updated to reflect the missing evacuation time, and the corrected form has been refiled with the appropriate supporting documentation. Additionally, the staff member responsible was retrained on the proper completion of fire drill documentation to prevent future errors. 06/17/2025 Implemented
SIN-00244518 Renewal 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)There were no attestations that the newly hired staff members with PA State Police Criminal History Background Checks and no FBI criminal history record checks have lived in PA for the past two years.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. All prospective employees apply through an online portal. On the online application, there is an attestation that the newly hired staff members have lived in PA for the past two years. An application for a Federal Bureau of Investigation (FBI) criminal history record check is submitted to the FBI in addition to the Pennsylvania criminal history record check for all prospective staff that have not lived in PA for the past two years. (attach application of staff reviewed and highlight attestation section). 05/14/2024 Implemented
6400.64(b)There were ants found in several areas of the home (baseboard of the dining room, kitchen counter, and kitchen windowsill).There may not be evidence of infestation of insects or rodents in the home. On 5/17/24 the home was treated for initial ants pest management. Treatment will continue monthly until home is free of ants infestation. (Attach receipts of pest control treatment) 05/17/2024 Implemented
6400.64(f)The trash cans at the back of the house were overflowing, making it so that the lid couldn't close. Utilize the second waste bin, or purchase another to ensure that there are enough receptacles to hold all garbage.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Another Big trash can with a lid has been added to the ones outside the home to ensure more space for proper trash storage. (Photos of bins with lids) 05/16/2024 Implemented
6400.141(c)(10)The current physical form for individual 1 did not answer if the individual was free of communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. During the original annual physical exam on May 3rd, 2024, staff requested the primary care physician (PCP) to complete the section of the physical exam related to communicable diseases and TB. However, the physician prioritized addressing Individual 1¿s diabetes, ordering comprehensive blood work and informing staff that she will complete the communicable disease and TB test components during the follow-up visit on August 5th. As the result of this citation from a recent inspection, staff consulted with the physician to expedite the TB PPD test. Consequently, the test has been advanced to an earlier date. An appointment has been set for May 28th at 9 AM, at which time the TB PPD test will be administered to Individual 1. The physician will complete the physical examination form once the results are available. 05/22/2024 Implemented
6400.141(c)(14)The current physical form for individual 1 did not answer the "info pertinent to diagnosis in the event of an emergency" section.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The section labeled "info pertinent to diagnosis in the event of an emergency" on the physical examination form for Individual 1, conducted on May 3rd, 2024, was incomplete. Despite the form being highlighted by the nurse and instructions given to staff to ensure it was fully completed by the physician during the individual's visitation, the physician decided to await the results of comprehensive blood tests before providing the necessary information. This decision was due to the lack of continuous medical records for Individual 1. The attending physician agreed to complete the "info pertinent to diagnosis in the event of an emergency" section after analyzing the results of the ordered blood tests. This ensures that the emergency information provided is based on accurate and current health data. The completion will be performed during the scheduled follow-up visit on August 3rd, 2024. 05/15/2024 Implemented
6400.32(r)The signed individual rights form for individual 1 does not include information about subsection "r" pertaining to the right to have a lock on the door.An individual has the right to lock the individual's bedroom door.Program Specialist did not update individual rights as per bulletin. Individual¿s forms/consents have been updated to include that an individual has the right to lock the individual's bedroom door. Consents have been reviewed with the individual and signed. 05/14/2024 Implemented
6400.163(f)The individual 1's insulin was found in a plastic bag on a shelf in the refrigerator.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.A separate locked refrigerator has been purchased in the home to store only medication that requires refrigeration. (Picture of Refrigerator) 05/19/2024 Implemented
SIN-00224776 Renewal 05/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trash cans located in the backyard did not have lids.Trash receptacles over 18 inches high shall have lids. The trash cans located in the backyard were replaced with new trash cans that have lids that are attached to the base of the trash can. DSS to conduct monthly checks to ensure backyard trash cans are covered with lids Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/20/2023 Implemented
6400.66The light in the backyard was not operable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A contractor was hired to replace the broken motion sensor light in the backyard. The light has been replaced and is fully operable as of 5/18/2023. Going forward, CEO/COO to perform a test annually to ensure exterior lights are operable. 05/18/2023 Implemented
6400.67(a)The wall around the toilet in the upstairs bathroom had a large gap space that needs to be repaired.Floors, walls, ceilings and other surfaces shall be in good repair. A professional contractor was hired to address the opening behind the toilet. In order to provide sufficient space behind the toilet tank, the original 12-inch toilet bowl was replaced with a more compact 10-inch bowl. This adjustment allowed for the installation of a plywood panel to cover the gap. The plywood was carefully fitted and painted to ensure a seamless and aesthetically pleasing outcome. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under training. 06/20/2023 Implemented
6400.70The phone in the home was not operational.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The phone lines were not functioning due to technical issues with our ISP provider, Comcast at the time of inspection. To address this problem, the Chief Operating Officer (COO) promptly contacted Comcast Technical Support to request assistance in resolving the issue. As a result, the phone lines have been repaired, and we can confirm that the phone system is now fully operational. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/18/2023 Implemented
6400.77(b)The First Aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer was immediately purchased and placed in the first aid kit. The DSS Shift Lead will conduct monthly checks of the first aid kit to ensure that all required items, including the thermometer, are present. This will help maintain the completeness of the first aid kit and ensure the availability of essential items. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under training. 05/20/2023 Implemented
6400.101The front bedroom had a latch door lock the has no key for entry or exit if needed.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The latch on the entry door to the master bedroom has been immediately removed, ensuring unobstructed access to the room. Going forward, the DSS and PS will prioritize maintaining clear and unobstructed egress routes throughout the facility, adhering to regulation 6400.101. This corrective action promotes the safety and timely evacuation of individuals during emergencies. 05/23/2023 Implemented
6400.151(a)There were a number of staff who did not have a physical exam in the provider's record during the review for the following staff: · Staff number 1, 2, 3, 4, and 5. · A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The staff members (#1, #2,#3,#4,#5) mentioned in the citation have undergone their respective physical examinations as of 6/21/2023. Copies of their completed physical examination forms will be kept in the HR's employee medical record folder for review. Going forward, the CEO will collaborate closely with HR personnel to ensure that all current and future employees have completed physical examination forms as mandated by regulations 6400.151(a). Note: UFIL INC was not providing services to any individuals at the time of this citation. 06/21/2023 Implemented
SIN-00205621 Renewal 05/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a empty unlabeled bottle in the same closet as chemicals used for cleaningPoisonous materials shall be stored in their original, labeled containers. Immediate action taken (What will/have been corrected): All unlabeled bottles were removed from the Utility closet and disposed of. A thorough search for unlabeled bottles or unlabeled products deemed poisonous by 6400.62(c) was done throughout the house and DSS confirmed that there were no more unlabeled bottles in the residence. Places checked: 1. Cabinet space under Kitchen Sink: OK 2. Cabinet space under Bathroom Sink: OK 3. Tower/supplies closet on second floor: OK 4. Closet in each of the three bedrooms on the 2nd floor: OK 5. Main entrance Closet: OK 6. Utility Closet in the Basement: OK UFILC has instructed DSS and PS that unlabeled bottles are not kept at the residence. Administration Training: An analysis and copy of the POC has been printed, signed, and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/25/2022 Implemented
6400.64(a)The refrigerator was not clean. There was a black unidentified substance throughout inside refrigerator. Dirt build up was present on refrigeratorClean and sanitary conditions shall be maintained in the home. Immediate action taken (What will/have been corrected): The refrigerator was emptied and cleaned thoroughly (interior and exterior). All black residues have been removed. The Freezing compartment was defrosted and cleaned. The exterior of the refrigerator was cleaned and polished. Going forward, once the residence begins servicing individuals, the Shift Lead will be responsible for inspecting the residence to ensure that clean and sanitary conditions are met daily. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/25/2022 Implemented
6400.67(b)Broken hanging clothes rack in the bedroom of Andrew Cattle Floors, walls, ceilings and other surfaces shall be free of hazards.Immediate action taken (What will/have been corrected): The broken hanging clothes rack was removed from the bedroom and all remaining residues were cleaned up; the room is free of all hazardous material. A new clothe rack was purchased and installed in the bedroom. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/26/2022 Implemented
6400.163(h)Medication (monetosone cream) for individual #1 was not disposed properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Immediate action taken (What will/have been corrected): The Magnetozone cream in questioned was removed from the residence and disposed of at the Yeadon Borough Police station on Church Lane. Going forward, excess and discontinued medications to be disposed of at police station or Walgreens pharmacy with disposal drop boxes. Administration Training: An analysis and copy of the POC has been printed, signed and dated. Placed inside of the CEO¿s Staff binder under trainings. 05/18/2022 Implemented
SIN-00188017 Initial review 05/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The thermometer that was used for the inspection was not working properly, and was not able to take the water temperature. Hot water temperatures in bathtubs and showers may not exceed 120°F. Immediate action taken (What will/have been corrected): A New digital thermometer was purchased on May 30, 2021. (Enclosed is the receipt of the purchase and a photo of the thermometer - please refer to: Attachment #4) 1. To ensure the new thermometer was working properly. A water temperature test was conducted on: May 30,2021. 2. Area's that was tested: Shower/ tub area measured: 93 degrees F (please refer to Attachment #5). 3. Kitchen sink measured:100 degrees F (please refer to Attachment #6). 4. Bathroom sink measured. 99 degrees F (please refer to Attachment #7). To ensure the current water temperature did not exceed 120 F. 05/30/2021 Implemented
6400.111(a)The basement did not have a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Immediate action taken (What will/have been corrected): There is a tagged Fire Extinguisher installed in the doorless closet in the Basement. To help identify the location of the fire extinguisher, a fire extinguisher sign has been mounted on the door frame next to the equipment on May 30, 2021. (please refer to attachment #1). Note: Three fire extinguishers were inspected and tagged by the Delaware Valley Fire Equip Co on February 09, 2021 for the 817 Laurel Road resident (please refer to attachment #2). The Fire extinguishers were installed on the 2nd floor, 1st floor and in the Basement. 05/30/2021 Implemented