Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280091 Renewal 12/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At time of inspection there was a very thick accumulation of spackling dust on the baseboard trim at the end of the hallway.Clean and sanitary conditions shall be maintained in the home. The dust was cleaned on 12/31/25. 12/31/2025 Implemented
6400.82(f)There was no hand soap in the small ensuite bathroom of the home. A new bag of soap was placed into the dispenser at time of inspection.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. Hand soap was added to the ensuite bathroom on 12/29/25. 12/29/2025 Implemented
6400.181(a)The initial Individual Skills Assessment dated 5/10/25 located in the Individual's file and presented as the current document at the time of inspection was not complete. The skills assessment documents the level of ability from "Independent" to Supervision Only" with skill levels in between. The areas titled "Shaving," "Personal Health," "Financial Management," "Safety/Mobility," "Kitchen/Cooking," "Living Area" were blank. The assessment presented was not a complete assessment of adaptive behavior and level of skills required to provide care in the specified areas. A completed version of the assessment was presented upon request on 12/30/25. 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. Skills assessment was updated and completed on 12/30/25 12/30/2025 Implemented
6400.181(e)(5)It was reported at the time of inspection that Individual #1 was admitted into the program on 4/11/25 with the ability to self-administer their medications. The "Individual Skills Assessment" portion of the initial assessment for Individual #1 was completed on 5/10/25 and did not properly assess the individual to be self-medicating. The document contains three areas to be assessed as "Selects correct medication from cabinet," "Selects proper dosage of medication," and "Takes medication at correct time." Each item was left blank with no information completed to indicate that the Individual's ability had been assessed as required. The narrative section of the assessment does not indicate that Individua #1 is able to identify pills, distinguishing them one from another. There was no documentation to illustrate that Individual #1 was able to recognize and distinguish the individual's medication, know how much medication is to be taken, know when the medication is to be taken and independently take or apply the individual's medication with or without the use of assistive technology as required to be considered self-medicating.The assessment must include the following information:  The individual's ability to self-administer medications.Assessment was updated and completed for the individual on 12/30/25. 12/30/2025 Implemented
SIN-00239397 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons shall be kept locked or made inaccessible. There was a plastic storage bin containing rock salt on the side porch of the home. The bin had a padlock on it, but the padlock was open at the time of the inspection, resulting in the rock salt being unlocked and accessible to the individuals residing in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. Lock was locked immediately at time of inspection. Staff were reminded that rock salt is considered a poisonous substance. 03/11/2024 Implemented
6400.66The front porch of the home did not have a functioning light at the time of inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Front porch light was replaced and functioning. 02/29/2024 Implemented
6400.111(c)There was not a fire extinguisher with a minimum 2A-10BC rating located in the kitchen of the home. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Fire extinguisher was placed in the kitchen of the home. Completed work order submitted. 03/05/2024 Implemented
6400.213(1)(i)Individual #1's record did not document the individual's height, weight, hair color, eye color, identifying marks and religious affiliation or preference.Each individual's record must include the following information: The race, height, weight, color of hair, color of eyes and identifying marks, The religious affiliation.Intake form put in individuals book at the time of inspection. 02/27/2024 Implemented
SIN-00184404 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The recliner located in the living room had an excessive amount of the material missing and peeling off. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. Recliner was removed from the premises and a new chair was purchased on 3/30/21. Receipts attached. 03/30/2021 Implemented
6400.73(a)There are two ramps located out the front door exit. Neither ramp has a hand railing. Each ramp shall have a well-secured hand railing. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 4/1/21, Arc maintenance attached a white PVC handrail to the home that provides support when utilizing both ramps. See attached completed work order. 04/01/2021 Implemented
6400.112(c)Fire drill conducted on 11/25/2020 at 12:45 am did not record an evacuation time.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. It is the responsibility of the Program Specialist to double check and ensure that all required information related to regulation 6400.112c is included. Any discrepancies on the form with be returned to the CLA supervisor for correction. 03/30/2021 Implemented
SIN-00169138 Renewal 01/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)There are approximately 7 steps leading up through the Bilco doors in the basement. There is no handrail at this exit. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Handrails were installed and secured and rechecked for safety. Prevention/Correction: All supervisory staff and program specialist discussed and reviewed regulation 6400.73(a). Maintenance Department also informed of the need for handrails when installing ramps that exceed two steps. Program Specialists will check handrails during weekly visits and whenever new ramps and interior stairways are constructed and maintain records of the findings of their checks. 02/04/2020 Implemented
SIN-00089411 Renewal 02/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The exit out in the back of the house has a ramp with no handrail, which is a safety issue. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Handrails were installed and secured. Completion Date: 3/18/2016 Person Responsible: Joseph Sepe All supervisory staff and program specialist discussed and reviewed regulation 6400.73(a). Maintenance Department also informed of the need for handrails when installing ramps that exceed two steps. Completion Date: 2/11/16 Person Responsible: Sheila Nealon 03/18/2016 Implemented
SIN-00055913 Renewal 11/20/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1 made a purchase on 08/28/2013 for $22.98 and there wasn't a receipt(3) Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Duplicate copies of receipts over $15 will be maintained. Currently, receipts are copied, sent to Advocacy Alliance, Rep. payee, and kept on file at the home and the office. One additional copy will be made. 11/20/2013 Implemented
6400.68(c)Two Coliform Water Tests were missed between October of 2012 and July of 2013(c) A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. Coliform water tests will be completed every 3 months and results will be kept on file at the home and office. Testing dates will be recorded on both the PS and Home supervisor calendar to ensure prompt testing. 11/20/2013 Implemented
6400.112(d)On September 5, 2013 the evacuation time for a fire drill was 2 minutes and 45 seconds.(d) 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 employee 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. On Sept. 5, 2013 @ 6AM a test overnight drill was completed because JD was experiencing an overall decline in mobility. On Sept.6, 2013, we provided additional staffing during sleep hours to ensure JD's safety. We also requested and received Additional Individualized Staffing. Since the additional overnight staffing has been in place, JD has evacuated within the 2.5 minute time frams. 09/06/2013 Implemented
6400.141(c)(6)Individual #1 did not have a Tuberculin skin test completed within the two year time frame.(6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. A desensitization plan was put into effect following the individual's refusal for the Mantoux test. Individual had a Mantoux test on 6/26/2013. The individual will have a TB skin test within a two year time frame. 11/20/2013 Implemented
6400.144Artificial Tears was prescribed for Individual #2-------The original order stated to administer the eye drops four times per day, the medication label and the medication administration record stated to administer the eye drops every hour from 8am to 8pm and the CLA staff said that they administer this medication only during awake hours-----------there are too many discrepancies regarding the correct administration of this medication.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. Prescribing physician contacted and clarified administration of artificial tears; one drop, left eye, each hour for awake hours. 11/20/2013 Implemented
SIN-00129465 Renewal 02/20/2018 Compliant - Finalized