Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285371 Renewal 03/19/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The refrigerator in the office needs to be cleaned. Inside the kitchen oven and oven door had baked in dirt and grime.Clean and sanitary conditions shall be maintained in the home. The refrigerator was cleaned on 3/20 (Supporting Document S7). 03/20/2026 Implemented
6400.64(e)There were no lids on the trash receptacles outside.Trash receptacles over 18 inches high shall have lids. Replacement trash cans were purchased the week of 3/23 (Supporting Document S8). 03/23/2026 Implemented
6400.66The outside of the door of the office did not have an operable light. There was no lighting for the outside basement steps.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light operates via motion and light and turns on in in the dark (Supporting Document S9). 03/31/2026 Implemented
6400.73(a)There were no handrails for the outside basement steps. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The Handrail was installed on 4/2/26 (Supporting Document S10). 04/02/2026 Implemented
6400.101The stairs from the 1st floor office to the 2nd floor office were covered with mail.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The stairs were cleaned on 3/20(Supporting Document S11). 03/20/2026 Implemented
6400.151(a)The last two physicals dated 1/17/2023 and 2/4/2025 -- both exceeded the 5-day grace period for staff member #4. 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 Residential Director tracks staff physicals on a grid. In the future staff will be directed to obtain their physicals at least one month prior to expiration. 04/09/2026 Implemented
6400.151(b)The 2/4/2025 physical for staff member #5 was completed. However, it did not have a name of the person examined. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. In the future the Residential Director will review all physicals prior to a staff starting, staff with physicals missing required documentation will not be permitted to work until documentation is completed. All other staff physicals were reviewed for proper documentation 04/09/2026 Implemented
6400.171Some meat in the office freezer was expired, and some were poorly packaged with no labels and significant frost. Although the food was frozen, there was a significant odor from the aged food in the freezer.Food shall be protected from contamination while being stored, prepared, transported and served. The freezer was cleaned on 3/20 (Supporting Document S12). 03/20/2026 Implemented
6400.52(c)(1)Staff member #1's training record for the most recent, complete training year (7/1/24-6/30/25) did not fulfill the requirements outlined in the regulations at 52(c)(1-6).The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.This staff has completed 52©(1-6) trainings for 7/1/2025-6/30/2026 (Supporting Document S35). 04/02/2026 Implemented
6400.52(c)(2)There was no record of a training for prevention, detection and reporting of abuse, suspected abuse and alleged abuse training during the training year 7/1/2024-6/30/2025 for staff member #3.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.This staff has completed (Supporting Document 33) For 7/1/2025-6/30/2026. 04/02/2026 Implemented
6400.52(c)(2)The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. , K§ § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations was last recorded 5/29/2024 -- but none recorded within the 7/2024-7/2025 training year for staff member #2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.This staff has completed recognizing and reporting abuse training (Supporting Document 33) for 7/1/2025-6/30/2026. 04/02/2026 Implemented
6400.52(c)(4)There is no record of a training for recognizing and reporting incidents during the training year 7/1/2024-6/30/2025 for staff member #3.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.This staff has completed Recognizing and Reporting Incidents training for 7/1/2025-6/30/2026 (Supporting Document S33). 04/09/2026 Implemented
6400.52(c)(4)Recognizing and reporting incidents was last recorded as 5/29/2024 -- but none recorded within the 7/2024-7/2025 training year for staff member #3.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.This staff has completed Recognizing and Reporting Incidents training for 7/1/2025-6/30/2026 (Supporting Document S33). 04/09/2026 Implemented
SIN-00243481 Renewal 04/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light in individuial 3's bedroom was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light was replace on 5/15/24 (Supporting Document S13). 05/15/2024 Implemented
6400.10610/27/23 heating tune-up recommended a repair of a leak found on 1-1/4" black iron condensate return line and also recommended a new sight glass valve kit.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 leak was repaired on 11/9/2023 (Supporting Document S6). The documentation for this was sent to the inspector during inspection. In 05/01/2024 Implemented
SIN-00224058 Renewal 04/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Lint trap in the upstairs laundry room was completely full. This was cleaned out while the inspector was still onsite. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint trap was cleared during inspection. The Program manager has been retrained on ensuring all lint traps are cleared between each load (Supporting Document S1) 05/02/2023 Implemented
6400.82(f)There was no toilet paper in the upstairs hallway bathroom. This was added to the bathroom while the inspection was still onsite.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The toilet paper was replaced during inspection. 05/02/2023 Implemented
6400.181(e)(14)The assessment does not specifically address Individual 1 and Individual 2's ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The assessments have been updated to reflect the individual¿s ability to swim (Supporting Document S3). 05/02/2023 Implemented
SIN-00203949 Renewal 04/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)There was a soda bottle in the same closet as chemicals used for cleaningPoisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.The soda bottle was removed during inspection. Following inspection the home was searched for any other food/beverages being improperly stored. There were no other food/beverage items that were improperly stored and needed to be moved or removed 04/27/2022 Implemented
6400.64(a)The refrigerator was not clean. There was a black unidentified substance throughout inside refrigerator. Dirt build up was present on the refrigerator.Clean and sanitary conditions shall be maintained in the home. The refrigerator was deep cleaned following inspection. 04/27/2022 Implemented
6400.67(b)There was a broken hanging clothes rack in the bedroom of individual #1. Floors, walls, ceilings and other surfaces shall be free of hazards.The clothes rack was repaired during the week of 4/25 (SF2). 04/27/2022 Implemented
6400.141(c)(4)The annual physical question regarding hearing test is blank for individual #2.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A hearing test was completed on 12/7/22 (Supporting Document SF8). All findings were within normal limits. 12/07/2022 Implemented
6400.217A Consent for release of information was not found in the record for individual #2.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. The release of info was signed on 12/2/22 (SF6). 12/02/2022 Implemented
6400.163(h)The 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.The cream was disposed of following inspection. 04/27/2022 Implemented
SIN-00186411 Renewal 03/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The Fire drill dated 1/25/2021 for 928 Lindale street exceeded 2.5 minutes, at 3 minute total time. A subsequent drill in the same month was not completed. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The staff administering the training was retrained on 5/12/21 (Supporting Document #12). The fire drill form was also revised to highlight the required timeframe (Supporting Document #9). 05/12/2021 Implemented
6400.113(a)Fire safety training was not completed upon admission, There was no documented fire safety training for individual 1. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Upon starting, the Director of Residential recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. 04/01/2021 Implemented
6400.141(a)A current physical exam for individual 1 was not available at time of inspection. The last physical exam was completed on 11/18/2019.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. A physical for this individual was completed on 3/30/21 (Supporting Document #10 03/30/2021 Implemented
6400.144Vision exams for individual 1 are not kept current. Recommended for every 6 months on previous vision exam, more than 6 months have lapsed between vision exams.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A vision exam for this individual was completed on 5/4/21 (Supporting Document #11). 05/04/2021 Implemented
6400.181(a)Only assessment available is dated 3/4/21, there was no documentation that the assessment was completed on an annual basis for individual 1. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Upon starting, Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. 04/01/2021 Implemented
6400.34(a)Verification that individual rights were reviewed annually with individual 1 was not was received.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Upon starting, Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. 04/01/2021 Implemented
6400.165(c)Flonase was not administered from March 1-20 for individual 1. Flonase was misplaced by individual while on a previous home visit per agency statement and not available to be administered.A prescription medication shall be administered as prescribed.Medication was procured from pharmacy and administered. Error was also entered into EIM. 05/03/2021 Implemented
SIN-00266047 Renewal 04/28/2025 Compliant - Finalized