Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00289760 Renewal 05/29/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the home was 143 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The Executive Director/Program Specialist corrected the violation by adjusting the hot water heater so that the water temperature at all bathtubs and showers does not exceed 120°F. The temperature was rechecked and verified to be within the required limit. See Attachment. 05/29/2026 Implemented
6400.81(k)(4)The 3rd floor bedroom did not contain a dresser/chest of drawersIn bedrooms, each individual shall have the following: A chest of drawers. The Program Specialist corrected the violation by providing a dresser/chest of drawers in the third-floor bedroom to ensure the room meets the requirements of Chapter 6400. See Attachment. 05/29/2026 Implemented
6400.110(e)The smoke detectors in the home were each independently operable, but were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The Program Specialist corrected the violation by having a qualified vendor interconnect the home's smoke detectors so that they are audible throughout the residence in accordance with Chapter 6400 requirements. See the attachment for vendor documentation verifying that the corrective action was completed. 06/05/2026 Implemented
6400.111(f)The fire extinguisher on the 3rd floor was last inspected in June of 2024, which is greater than 1 year ago. 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 Program Specialist immediately corrected the violation by having the third-floor fire extinguisher inspected and certified by a qualified fire safety expert on May 29, 2026, with the inspection date affixed to the extinguisher. See Attachment #4 for documentation of the completed inspection. 05/29/2026 Implemented
6400.112(e)A sleep fire drill was conducted in 8/2025 and there hasn't been one since, which is beyond 6 months. This was the only sleep fire drill in 2025.A fire drill shall be held during sleeping hours at least every 6 months. The Program Specialist corrected the violation by conducting a sleep fire drill and re-establishing the required schedule to ensure sleep fire drills are conducted at least every six months. See Attachment #5 for documentation of the completed sleep fire drill. 05/29/2026 Implemented
SIN-00229754 Renewal 08/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There is no ventilation in the bathroom, the ceiling fan is not operational.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The provider maintenance team has completed repairs of the vent in the bathroom. Completed on 08/24/2023 08/24/2023 Implemented
6400.77(b)The first aid kit did not contain a thermometer at the time of inspection, corrected at inspection. 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. The Provider added the thermometer at the time of the inspection. Completed on 08/23/2023 08/23/2023 Implemented
6400.111(a)There is no fire extinguisher located on the third level of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Provider¿s maintenance team installed a new fire extinguisher on the 3rd floor of the house. Completed 08/24/2023 08/24/2023 Implemented
6400.112(e)Sleep drills for this home were held on 8/4/22 and then again on 5/15/23 which was over the regulatory time frame.A fire drill shall be held during sleeping hours at least every 6 months. The Provider has developed a fire drill schedule to be used across the agency to ensure all drills are conducted timely as required by regulations. Completed on 09/01/2023 09/01/2023 Implemented
SIN-00209966 Renewal 08/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(a)The home did not have a first aid kit at time of inspection. A home shall have a first aid kit. The Provider has provided a first aid kit in the home and will ensure there is a First Aid Kit in each of its sites containing all the needed items readily available for use by staff and consumer at all times, according to PA Code Chapter 6400.77 (a), to remain in compliance. 08/22/2022 Implemented
6400.111(a)There was no fire extinguisher located on the second floor.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Provider has provided a new fire extinguisher on the second floor of the home which was inspected and tagged. The Provider will ensure there is an operable Fire Extinguisher on each floor in all of its sites, inspected and tagged annually to maintain compliance according to PA Code Chapter 6400. 111(a). 09/22/2022 Implemented
SIN-00175461 Renewal 08/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The baseboard in the living room area was found with dirt on its surface. The bathtub was found dirty on its surface.Clean and sanitary conditions shall be maintained in the home. Agency will ensure baseboards in residential sites are kept clean and in sanitary conditions, the bathtub will be refurbished and kept clean with ongoing maintenance conditions in according with 55 PA Code Chapter 640064(a). The Residential Manager will be responsible for this function. 01/14/2021 Implemented
6400.67(b)The carpet was found bunched- up in the living room area resulting in a potential tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Agency is in the process of replacing the carpet in the living room to avoid a potential tripping hazard in according with 55 PA Code Chapter 6400 .67(b). The Executive Director will be responsible to replace the carpet. 01/31/2021 Implemented
6400.76(a)The kitchen area has a sofa with the center cushion peeling and having a urine smell. Individual # 1 was reported by staff as having incontinence issues. Furniture and equipment shall be nonhazardous, clean and sturdy. Agency Management will remove the sofa from the kitchen and be replaced it with non-hazardous furniture, that will be clean and sturdy at all times. The Residential Manager will be responsible to ensure this site is well maintain in according with 55 PA Code Chapter 640076(a) 01/31/2021 Implemented
6400.76(a)The kitchen area had a sofa with peeling cushions and a urine smell. Furniture and equipment shall be nonhazardous, clean and sturdy. Agency Management will remove the sofa from the kitchen and be replaced it with non-hazardous furniture, that will be clean and sturdy at all times. The Residential Manager will be responsible to ensure this site is well maintained in according with 55 PA Code Chapter 640076(a) 01/31/2021 Implemented
6400.113(a)Individual #1 annual fire safety was last completed on 05/02/19. 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. Commonwealth's management will ensure that individuals participates in Annual fire safety procedures which will be done monthly and records are kept on site for review upon request. The residential manager will be responsible to complete and document all individuals fire safety drills in according with 55 PA Code Chapter 6400 .113(a). 01/31/2021 Implemented
6400.142(g)Individual #2 had his last dental hygiene plan last completed on 9/28/18.A dental hygiene plan shall be rewritten at least annually. Agency Management will follow 55 PA Code Chapter 6400142(g) regulation making sure all individuals dental hygiene plans are completed timely, and annually and records are kept in their medical books. The Residential Manager will be responsible to ensure all dental appointments are scheduled and attended by program participants. 01/31/2021 Implemented
6400.34(a)Individual # 1's last rights training was documented on 05/02/19The 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.Agency Management will ensure all individuals on caseloads receive training annually on their individual rights. The Program Specialist will be responsible to ensure individual #1 receive rights training annually and records are updated in the program book in accordance with 55 PA Chapter 6400.34 (a) 01/08/2021 Implemented
SIN-00148525 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were black stains consistent with dirt build up in the oven in the kitchen.Clean and sanitary conditions shall be maintained in the home. Upon discovery, the oven was cleaned thoroughly (Pictures will be submitted on a separate email) CSS also inspected other residential facilities to make sure all appliances including oven are clean and sanitary. staff were retrained in the proper cleaning procedure and maintaining a clean environment for our Individuals. A cleaning check list has also been developed and is being utilized by staff on a daily basis. the site supervisor does weekly monitoring to ensure that adequate clean and sanitary conditions are met in each home. Going forward, CSS Quality Assurance director will complete a quarterly physical site inspection to ensure compliance with the 6400 regulations. 05/14/2019 Implemented
6400.77(b)The first aid kit was missing tweezers. 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. Upon discovering that tweezer was missing from the first aid kit, CSS purchased tweezers and placed in the first aid kit. The site supervisors also inspected all other first aid kits to make sure contents were complete in the kit. Staff were trained on the importance of maintaining a complete first aid kit in each residential home. A first aid kit content sheet has been created and posted on the box and staff are required to check the first aid box at the end of the day making sure what is in the sheet reflects the content in the box. Going forward, the site supervisor shall do a weekly check of the First aid kit. the Director of Quality Assurance shall monitor this plan to make sure it is working in line with the regulations. 05/14/2019 Implemented
6400.183(5)Individual #1 is on Risperidone to treat psychotropic illness but there was no SEEP developed.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. There is actually a Social Emotional Protocol in the individual's ISP. However, CSS program specialist developed a SEEP upon realizing that Individual #1needs SEEP ( copy of the SEEP will be sent in a separate email). CSS also reviewed all Individual's medications to identify and develop a seep for those on psychotropic meds. Going forward, the program specialist shall in collaboration with behavior specialist develop SEEP for all Individuals as needed. The director of quality assurance shall review all individual's record to ensure all documentations required under the 6400 regulations are present and up to date. 05/14/2019 Implemented
SIN-00126945 Renewal 11/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment dated 10/31/17. License expired 11/13/17The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Current License expires 11/13/18. CSS will ensure Self Assessment is completed and submitted 5/18-8/18. QI Manager will ensure Self Assessment tools are distributed to all departments before 5/18 12/01/2017 Implemented
SIN-00271711 Renewal 08/06/2025 Compliant - Finalized
SIN-00249642 Renewal 08/13/2024 Compliant - Finalized