Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00282015

Renewal

01/21/2026

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(b)	At 9:42 AM on 1/22/26, there were two exposed, cut wires extending approximately two feet from the left side of the fuse box located in the home's basement. One of the two wires was uncapped, exposing its interior elements that posed a hazardous condition.	Floors, walls, ceilings and other surfaces shall be free of hazards.	The two exposed wires located at the site were capped, to reduce the risk of any interior hazards in the home. Site Lead will continue to ensure on a weekly basis that the site is free of hazards. The Site Lead will communicate any Maintenance and Remediation Report to the Programs Administrator for support in regulatory compliance.	02/04/2026	Implemented
6400.104	The home's Fire Department Notification Letter, dated 4/1/20, was not kept current, as it stated that,"[Individual #1] is able to evacuate the building in under two minutes during a fire drill." However, Individual #1's Service Plan, last updated 7/23/25, indicated that, "[Individual #1] requires verbal prompts to exit the home when the alarm sounds."	The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.	An internal audit of all local Fire Department Notification letters was conducted as of 1/23/2026 through 1/26/2026 which provided insight on the needs of the individuals as well as the location of bedrooms of indivdiuals needing assistance. Clarity was provided in greater detail fro the Fire Department letter on 4/1/20 for Individual #1. A new local Fire Department Letter was provided to the Fire Deparment- with information on the site, bedroom location, and floorplan as of 1-26-2026.	01/30/2026	Implemented
6400.105	At 9:33 AM on 1/22/26, the following conditions regarding combustible materials located in close proximity to the electric hot water tank in the home's basement were present: a gas dryer was situated directly against the right side of this hot water tank; a black, plastic bucket was placed directly in front of this hot water tank collecting water from the appliance's discharge pipe; and an electric dehumidifier was situated approximately three inches to the left of this hot water tank.	Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.	The gas dryer, remains situated in its current location within the property as of the date of the site inspection. It is important to note that this home has been licensed for residential use for the past fourteen years. Throughout this extended period, the placement of the gas dryer has never presented any concerns or citations related to health, safety, or well-being for residents or staff. Furthermore, a thorough review confirms that the current configuration meets all relevant building code requirements and occupancy standards established for the municipality of North Braddock. Due to significant physical constraints of the existing structure, there are no viable architectural or structural modifications that can be executed to increase the square footage of the utility area. Consequently, it is impossible to reconfigure the layout to accommodate an alternate arrangement for the washing machine, the dryer, and the hot water tank. Given these spatial limitations, moving the appliance to any other location within the home is not a feasible option. We reaffirm that the existing placement of the gas dryer does not constitute a safety risk to the residents, the staff, or the physical structure of the home. Hot Water Tank Discharge Pipe: The discharge pipe for the hot water tank was immediately extended. This necessary adjustment ensures that the pipe now properly and securely reaches and terminates into the designated drainage system located in the basement, eliminating any potential for water pooling or hazard. Electric Dehumidifier Relocation: The electric dehumidifier was moved from its previous position to a new, more suitable location within the basement. This relocation was possible due to available space and was executed specifically to mitigate the risk of any potential interior hazards, such as tripping or obstruction, thereby enhancing the overall safety of the basement area.	02/03/2026	Implemented
6400.32(r)(1)	At 9:50 AM on 1/22/26, Individual #1's bedroom door was equipped with standard door lock assembly requiring a key to operate it from the outside. However, agency interviews revealed that Individual #1 does not have their own key to lock and unlock their bedroom door and that only staff are in such possession of one. Individual #1's content of records---including their current assessment, completed on 10/6/25, and Service Plan, last updated 7/31/25---neither indicated Individual #1's choice not to have a key to their bedroom door, nor informed of any inability for Individual #1 to manage possession of such a key.	Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.	Individual signed declination of a key access on her bedroom door. To address the use / need for keys for individual resident access and privacy, a one-on-one meeting was held with every Pathways Community Living resident to determine their desire for a door lock and/or key. Following this process, Individual #1 formally waived the right to have a key to the door. This decision was documented on 2-2-2026 by the staff member and Programs Administrator who conducted the meeting and gathered the information. Pathways Community Living will review the Key Access and Bedroom Lock agreement will be reviewed with every resident on an annual basis to provide access, freedom, choice, and control for the individual.	02/02/2026	Implemented
6400.50(a)	Direct Service Worker #1's annual training for the 2024-205 fiscal year did not document the trainer who had conducted the in-person courses completed on the following dates and required content topics: on 10/16/24---the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse; on 1/19/25---recognizing and reporting incidents; and on 5/13/25---individual rights.	Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.	The aforementioned trainings were completed by the individual but failed to have a Trainer on the documentation. All trainings that were conducuted by PCL Management, Executive Team, or Human Resources Director have been updated to include the appropriate trainer to support regulatory compliance.	01/30/2026	Implemented

SIN-00136348

Renewal

06/06/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.31(b)	Individual #1, date of admission 9/22/17, initially signed and dated a statement acknowledging receipt of the information on rights on 9/26/17.	Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept.	A formal paperwork review following the intake meeting must occur prior to the transition of a new individual to the agency. Agency policy change will require that all prospective or transitioning participants complete a intake meeting within 10 days prior to admission. Following the meeting the documentation must be reviewed for accuracy. This policy retraining will occur to ensure that such efforts are made to obtain the proper documentation prior to the receipt of home and community based services. Program Specialist and Site Supervisors will be retrained in this area on 7/31/2018. [Immediately, the CEO shall develop and implement a tracking system to ensure all individuals are informed of the information on rights, timely. Upon admission and at least quarterly for 1 year, the CEO shall audit statement signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights and the aforementioned tracking system to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)]	07/31/2018	Implemented
6400.81(k)(6)	There was not a mirror in Individual #1's bedroom.	In bedrooms, each individual shall have the following: A mirror.	Per the history of behavior of the individual it is not recommended to have a mirror in the bedroom. Documentation will be obtained from the family which provides insight on Individual #1's needs, as well as Individual #1 to indicate having no need for a mirror in the bedroom at this time. All other major furnishings are made available to the participant. A mirror is present in the bathroom adjacent to the participants bedroom. If the participant indicates a present need for a mirror it will be purchased now, and used in the event the participant and or the family has a change in their current wishes. The document will be uploaded to the participants file by 7/13/2018 as this has been verbally agreed upon sine September of 2017. [Individual #1's assessment updated on 7/13/18 indicated that Individual #1 did not want a mirror. The family and the SC were notified of the update to the assessment. Immediately, and continuing at least quarterly, the Program specialist shall review all individuals assessments and ISPs to ensure accuracy including Individual #1's preference for the presence of a mirror in Individual #1's bedroom. (DPOC by AES,HSLS on 8/23/18)]	07/13/2018	Implemented
6400.113(a)	Individual #1, date of admission 9/22/17, had initial fire safety training completed 9/26/17.	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.	Initial Fire Safety must be completed at the start of services with Pathways Community Living. The participant did not receive this training on the date of move in, only a fire drill was completed. Residential site supervisor, and Program Specialist have been made aware of the necessity of this compliance standard. Training on this topic was completed with the Program Specialist on 6/26/2018. Training for the residential supervisor was completed on 6/27/2018. [Immediately, the CEO shall develop and implement a tracking system to ensure all individuals are 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, timely. Upon admission and at least quarterly for 1 year, the CEO shall audit all individuals' fire safety trainings and the aforementioned tracking system to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)]	06/27/2018	Implemented
6400.141(a)	Individual #1 had a physical examination completed 4/21/17 and then again on 5/14/18.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	The Program Specialist will ensure that all participants are scheduled for a physical examination prior the expiration date. All participant physical examination information will be compiled in a electronic system to ensure that the date is not missed. A reminder alert for each physical examination and TB Test will begin 60 days prior to the expiration date to ensure proper time for scheduling. The Program Specialist will be responsible for the execution in the task, as well as informing the appropriate residential site supervisor of the requirement. Training on this matter was completed with site supervisors, and led by the Program Specialist on 6/27/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of individuals' current physical examinations to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)]	06/27/2018	Implemented
6400.151(a)	Direct Service Worker #1, date of hire 1/24/18, had a physical examination completed 1/31/18.	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.	Human Resources Generalist will support the review of all employee physical information to ensure that all direct service workers have a signed documentation from a physician indicating that they have undergone a physical prior to working with individuals. A new hire checklist has been implemented and reviewed weekly to ensure that all agency standards are withheld. A monthly review of employee health records will occur to ensure staff are meeting the minimum requirements. To ensure that staff physicals and TB test are up-to-date, Human Resources Generalist will compile a list of staff that need physicals and TB tests. This will be done by doing a review of employee medical files. Human Resources Generalist was trained on this information regarding regulatory standards on 7/6/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of staff persons' physical examinations to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)]	07/06/2018	Implemented
6400.151(c)(2)	Direct Service Worker #1, date of hire 1/24/18, had Tuberculin skin testing by Mantoux method with negative results completed 3/6/18.	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.	Human Resources Generalist will support the review of all employee physical information to ensure that all direct service workers have a signed documentation from a physician indicating that they are free of communicable disease. A new hire checklist has been implemented and reviewed weekly to ensure that all agency standards are withheld. A monthly review of employee health records will occur to ensure staff are meeting the minimum requirements. To ensure that staff physicals and TB test are up-to-date, Human Resources Generalist will compile a list of staff that need physicals and TB tests. This will be done by doing a review of employee medical files. Human Resources Generalist was trained on this information regarding regulatory standards on 7/6/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of staff persons' Tuberculin skin testing to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)]	07/06/2018	Implemented
6400.161(e)	Neosporin OTC Cream, Tylenol 500mg, and Diabetic Tussin DM Syrup were with Individual #1's medications and were reportedly discontinued.	Discontinued prescription medications shall be disposed of in a safe manner.	House Supervisors have been instructed to complete a weekly review of medication boxes to ensure appropriate medication is present for the participant. Medication administration recorders (MAR) are going to be crossed checked to the Medication blister packs and medication original labeled containers once a week by supervisors and the medication administration trainer. Also, during site inspections, the expiration dates of all medication will be checked. If any medication is expired it will be properly disposed of. A review of the medication will occur monthly by the Medication Trainer, with a report submitted to the Program Specialist based on findings. The Medication Trainer will be responsible for random checks of the medication boxes to be completed on a bi-weekly basis to improve quality control measures. The medication trainer was made aware of this procedural change as of 7/6/2018. Site Supervisors were made aware of these changes during a formal meeting on 6/27/2018. [On 7/30/18, the discontinued medications for Individual #1 were not in the home. Documentation of aforementioned medication audits shall be kept and reviewed by the CEO at least monthly to ensure all individual are administered medications as prescribed and documented as required and discontinued medications are disposed of in a safe manner. (DPOC by AES,HSLS on 8/23/18)]	07/06/2018	Implemented
6400.167(b)	Clotrim/Beta Cream Diprop, apply topically to abdomen daily prescribed for Individual #1 was most recently administered 6/2/18. Ciclopirox Sol 8% prescribed for Individual #1 was most recently administered 5/30/18. On 6/7/18, these medications were not in the home and available for administration.	Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.	House Supervisors have been instructed to complete a weekly review of medication boxes to ensure appropriate medication is present for the participant. Medication administration recorders (MAR) are going to be crossed checked to the Medication blister packs and medication original labeled containers once a week by supervisors and the medication administration trainer. Also, during site inspections, the expiration dates of all medication will be checked. If any medication is expired it will be properly disposed of. A review of the medication will occur monthly by the Medication Trainer, with a report submitted to the Program Specialist based on findings. The Medication Trainer will be responsible for random checks of the medication boxes to be completed on a bi-weekly basis to improve quality control measures. The medication trainer was made aware of this procedural change as of 7/6/2018. [On 7/30/18, the discontinued medication for Individual #1 were not in the home. Documentation of aforementioned medication audits shall be kept and reviewed by the CEO at least monthly to ensure all individual are administered medications as prescribed and documented as required and discontinued medications are disposed of in a safe manner. (DPOC by AES,HSLS on 8/23/18)]	06/27/2018	Implemented
6400.168(d)	Direct Service #2's certification to administer medication expired on 5/12/18 and was not recertified until 5/29/18. Direct Service Worker #2 administered medications to Individual #1 from 5/13/18 and 5/23/18.	A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually.	All practicums need to be completed at least a week be prior to the expired date to prevent any medication administration compliance errors. Also all practicums need proper cover sheets attached to file. A procedural change will go into effect as of July 2018 indicating that the Medication Trainer must submit a report identifying the completion of each Annual Practicum on a monthly basis to the CEO. Retraining on this information was completed during supervision with the Medication Trainer during the week of 7//2018. [On 7/30/18 during the POC verification a Med/Mar review was conducted for Individual #1 and there was a medication that did not match the MAR. The medication Fluocinonide Ointment .05% had a label that indicated: Apply topically twice a day to abdominal rash. The Mar indicated Apply to affected area once every morning. The Mar indicated that the medication was being administered once per day. [Immediately and continuing at least monthly for 1 year, the CEO and a certified medication trainer shall audit all staff person medication administration training to ensure completion. All staff person not certified to administer medications shall not administer medications. Immediately, the CEO and the certified medication trainer shall develop and implement a tracking system to ensure all staff persons who administer medications have completed the initial and annual medication administration trainings and practicums as required. At least quarterly for 1 year the CEO shall audit the aforementioned tracking system. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/23/18)]	07/06/2018	Implemented
6400.181(f)	The program specialist provided Individual #1's assessment completed 10/3/17 to the SC and plan team members on 12/1/17 for an annual ISP meeting on 12/12/17. (Repeated Violation-6/21/17, et al)	(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).	The identified error in sending the quarterly report to the Service Coordinator was based on the individual being in crisis. It is typical that all Residential Assessments are sent to the plan team in adequate within the specified timeframe it is due. All retraining efforts on this agency standard was discussed during supervision with the Program Specialist on 6/26/2018. [Individual #1's assessment completed 7/19/18 had been sent to plan team members on 7/28/18. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. Immediately, the CEO shall develop and implement a tracking system to ensure the program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting, timely. At least quarterly for 1 year, the CEO shall audit the tracking system and a 25% sample of correspondence documentation showing the program specialist has provided all individuals' assessments to the plan team members, timely. (DPOC by AES,HSLS on 8/23/18)]	06/26/2018	Implemented
6400.186(b)	The program specialist did not date the ISP review completed 3/31/18 for Individual #1.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	The ISP review was historically completed by the House Supervisor, and then submitted for approval by the Program Specialist. The document will be generated and approved by the Program Specialist; with the signature acknowledgment of the development of the ISP review. Any updates for the ISP have already been completed for this measure and will be entered accordingly to upcoming ISP Reviews effectively immediately. Retraining on this procedural change was discussed during supervision with the Program Specialist on 6/26/2018. [Individual #1's ISP review dated 3/31/18 was completed and signed by the program specialist on 7/13/18. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO shall audit a 25% sample of individual ISP reviews to ensure program specialist has completed the ISP reviews, timely. (DPOC by AES,HSLS on 8/23/18)]	06/26/2018	Implemented
6400.186(d)	The program specialist provided Individual #1's ISP review documentation completed 12/31/17 to the SC and plan team members on 3/19/18.	The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.	The identified error in sending the quarterly report to the Service Coordinator was based on the individual being in crisis. It is typical that all Quarterly Reports are sent to the plan team in adequate within the specified timeframe it is due. All retraining efforts on this agency standard was discussed during supervision with the Program Specialist on 6/26/2018. A peer review of ISP reviews will occur monthly by the Program Coordinator to ensure proper standards. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. Immediately, the CEO shall develop and implement a tracking system to ensure the program specialist shall provide the individuals ISP reviews to plan team members as required, timely. At least quarterly for 1 year, the CEO shall audit the tracking system and a 25% sample of correspondence documentation showing the program specialist has provided all individuals' ISP reviews to the plan team members as required, timely. (DPOC by AES,HSLS on 8/23/18)]	06/27/2018	Implemented

SIN-00116139

Renewal

06/21/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(a)	The register on the kitchen floor had three linear bars on the left side of the grille that were cracked and bent.	Floors, walls, ceilings and other surfaces shall be in good repair.	At the time recent to the inspection date, new flooring and kitchen was installed at the residential site. New floor installation provided a space and necessity for a new register to be placed on the floor for home ventilation. New floor registers have been ordered and installed at the home. The new registers reflect the updates which were completed at the residential site. The site will be in compliance with a new register as of 6/30/2017. All registers in the kitchen were replaced to reflect good repair. [At least monthly, the CEO or designee shall complete onsite monitoring of all community homes to ensure floors, walls, ceilings and other surfaces are in good repair. Within 30 days of receipt of the plan of correction, all staff persons shall be educated to monitor for the home to ensure that floors, walls, ceilings and other surfaces are in good repair throughout the course of their daily duties and address as need. (AS 7/7/17)]	07/02/2017	Implemented
6400.72(b)	The screen in the kitchen door has a 1 foot tear in the center that was covered with duct tape.	Screens, windows and doors shall be in good repair.	A new screen door has been purchased for installation on the backdoor of the residential site. The new screen door will ensure that all entries and exits to the home are in good repair and acceptable for daily use. The screen door was installed properly on 6/30/2017. Pathways Community Living will continue oversight of residential location to maintain good repair of the home.[Immediately, the CEO shall develop and implement policies and procedures to ensure community homes are in good repair and free from hazards. Within 30 days of receipt of the plan of correction, all staff shall be trained in policies and procedures and to monitor the homes during the course of their daily duties and implement procedures as appropriate. At least monthly for 6 months and then continuing at least quarterly, the CEO or designee shall complete onsite monitoring of all community homes to ensure all areas of the homes are in good repair and free from hazards. Documentation of onsite monitoring shall be kept. (AS 7/7/17)]	07/02/2017	Implemented
6400.73(a)	The three outside steps at the back of the home did not have a handrail.	Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.	There is a necessity for a handrail to be installed on the outdoor patio behind the home. The landing will need the handrail to ensure the safety of any participants using the steps to enter the backyard. The installation of the handrail was completed as of 6/30/2017. Presently the site is vacant and the ongoing maintenance will be taken into consideration.[Immediately, the CEO shall develop and implement policies and procedures to ensure community homes are in good repair and free from hazards. Within 30 days of receipt of the plan of correction, all staff shall be trained in policies and procedures and to monitor the homes during the course of their daily duties and implement procedures as appropriate. At least monthly for 6 months and then continuing at least quarterly, the CEO or designee shall complete onsite monitoring of all community homes to ensure all areas of the homes are in good repair and free from hazards. Documentation of onsite monitoring shall be kept. (AS 7/7/17)]	07/02/2017	Implemented
6400.110(e)	The home has three stories including a basement and does not have interconnected smoke detectors.	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.	Guardian Fire Protection services will be available at the site to prevent the opportunity for a fire to go undetected. An onsite meeting with Guardian Protection services was completed, for an overall assessment of the site during the week of 6/26/2017. Fire protection services are scheduled to be installed with the use of interconnected monitoring systems during the week 7/4/2017. The new residential site located at 1613 Grandview Avenue Braddock, PA 15104. The installation will provide and added protection to the safety and monitoring of a fire at the service location. Guardian will provide an update on the exact installation date during the week of 7/3/17, which is expected to be on or before 7/7/17. The ongoing compliance with these systems will be reviewed monthly by the site supervisor during monthly fire drills. [Documentation of monthly testing of smoke detectors and fire alarm systems shall be kept and reviewed by the CEO at least quarterly. (AS 7/7/17)]	07/02/2017	Implemented
6400.111(a)	There are not fire extinguishers in the basement and on the second floor 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.	It is a necessity to ensure standards of fire safety are met to comply with regulation standards. Two additional fire extinguishers have been purchased and placed at the residential site. The new fire extinguishers were placed on the 2nd floor and basement. This action will ensure safety in the event of the home. The ongoing compliance with fire extinguishers will remain a priority as a participant is identified for the site. [Immediately, and at least monthly for 6 months and continuing at least quarterly, the CEO or designee shall complete an onsite monitoring to ensure there is an operable fire extinguisher with a minimum 2-A rating on each floor of each community home which is accessible and inspected and approved annually by a fire safety expert. Documentation of onsite monitoring's shall be kept. (AS 7/7/17)]	07/02/2017	Implemented

SIN-00244289

Renewal

05/07/2024

Compliant - Finalized

SIN-00208005

Renewal

07/12/2022

Compliant - Finalized

SIN-00156085

Renewal

05/29/2019

Compliant - Finalized