Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269454 Renewal 07/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Both bathrooms in the home had decorative plain soap dispensers that were not the original labeled container.Poisonous materials shall be stored in their original, labeled containers. Decorative soap dispenser was immediately removed from the baths on 7.10.25 and replaced with soft soap in original containers. All In home supervisors and managers will be retrained on regulation 6400.62 by 8.5.25 07/10/2025 Implemented
6400.75(a)The metal bracket on the bottom right of the pull-down stairs to the attic was in disrepair, which made it unsafe to climb and access the attic to check the tag on the fire extinguisher. The fire extinguisher and smoke detector were visibly present.A landing shall be provided beyond each interior and exterior door that opens directly into a stairway. Metal bracket on the bottom right of pull-down stairs leading to the attic was repaired on 7.10.25. A picture of the repaired metal bracket and fire extinguisher tag was shared with lead inspector on 7.11.25 Maintenace team will be trained on 6400.75 by 8.5.25 07/10/2025 Implemented
6400.51(a)(1)Staff One Trainings were provided for 23/24. Inspector was not provided with complete Trainings for 24/25 -- Staff One only HAS 13.75 HOURS FOR MOST RECENT TRAINING YEAR. Staff 1 did not hit their required trainings by end of your current training year.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Training hours for team member was located after inspection which totaled the hours of 29 for the training year. New HR team will be trained on where to locate training material by 8.20.25. 08/01/2025 Implemented
SIN-00208219 Renewal 07/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Door leading to the back door hits the awning which is drooping down a bit causing resistance on the door when opened. Needs to be adjusted to ensure it is fully unobstructedFloors, walls, ceilings and other surfaces shall be in good repair. The Maintenance Director adjusted the door immediately after inspection on 7/15/22. The door now opens unobstructed and provides safe egress. 07/15/2022 Implemented
6400.112(e)The sleep drills were not completed every 6 months. There were no sleep drills conducted in the 6 month period between 1/1/2022 through 6/30/2022. A sleep drill was recently conducted in July 2022 and previously completed in December 2021.A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill was completed in July 2022 as noted. The next drill will be completed January 2023 to get on a 6 month schedule that ensures compliance. Additionally, Team Leads and Lead workers were trained on 6400.112(e) 07/01/2022 Implemented
6400.144The following two PRN medications prescribed to individual #1 were not present at site at time of inspection: Cetitizine Tab 10mg -- 1 tablet by mouth as needed each year from July 1 -- February 28 Hydrocort Cream 1% - Apply to affected area topically twice daily as needed for eczema rashHealth 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. The two PRN Medications were ordered by the Nurse and placed immediately in the medication box on 7/14/22. A medication audit was completed by the Nurse to ensure that all prescribed medications were present. 07/14/2022 Implemented
6400.34(b)There is no updated copy of signed individual rights for individual #1. Most recent copy is from July 9, 2021.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The Program Specialist discussed the individual rights statement and obtained a signature from individual #1 on 8/1/22. The statement is now filed in the individual's chart at the Peaceful Living office as well as in the individual's home in order to meet the standard in 6400.34(b). 08/01/2022 Implemented
SIN-00200403 Renewal 07/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was not a drill held in the month of June 2021. An unannounced fire drill shall be held at least once a month. The Fire Drill for this location was run on July 20. There was no drill run in June and no way to recreate this for the cited month. Starting in July 2021, Unnanounced Fire drills are held monthly and tracked on the fire drill check list by location, by the Director of Residential. 07/20/2021 Implemented
SIN-00116107 Renewal 04/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Dove Dermocare anti dandrof was left unlocked in the bathroom wich is also used as laundry room. Clear disinfectant spray, glass and multi purpose cleaner were left unlocked down the basement. Poisonous materials shall be kept locked or made inaccessible to individuals.All staff were trained on the storage of poisonous substances and spot checks are done several times a week by management staff. 11/30/2016 Implemented
6400.67(a)Th screen door at the back porch was rotted and cracked arround the handle and the center of the door.Floors, walls, ceilings and other surfaces shall be in good repair. The storm door was replaced immediately by the property resource manager and all household items are checked monthly by the maintenance team. 11/30/2016 Implemented
6400.112(d)The evacuation of the fire drill conducted on 8/28/16 was 2 minutes 43 seconds. 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. After discovering that they could no longer evacuate in 2 !/2 minutes I was able to do a high rate request to get double coverage on the overnight and at that point the fire drills were able to be done in less than 2 ½ minutes. Fire drills are done and submitted by the 25th of the month to ensure that there is time to redo and troubleshoot if a drill exceeds 2 ½ minutes. I can submit a years worth to back it up 11/30/2017 Implemented
SIN-00084868 Renewal 12/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 9/03/15 was not completed within 3-6 months prior to the expiration of the license on 11/11/15.The 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. management staff trained on the regulated time frame for self-assessments to be completed. Training sign in sheet attached. 03/11/2016 Implemented
6400.112(e)Between 12/1/2014 and 5/30/2015 there was not a fire drill held during sleeping hours.A fire drill shall be held during sleeping hours at least every 6 months. fire drills are monitored to ensure that the overnight drills are being completed within the regulated time frame. Seven months of fire drills attached. 10/27/2016 Implemented
SIN-00093327 Renewal 12/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 9/03/15 was not completed within 3-6 months prior to the expiration of the license on 11/11/15.The 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. All staff in the position of conducting the annual self-inspections have been educated on the regulatory time frame for completing self-inspections in relation to the licensing expiration date. 09/14/2016 Implemented
6400.112(e)Between 12/1/2014 and 5/30/2015 there was not a fire drill held during sleeping hours.A fire drill shall be held during sleeping hours at least every 6 months. Schedule of fire drills moving forward include asleep drills every 3 to 4 months to ensure compliance with 6400.112(e). The Residential Director is responsible to review drills monthly to ensure compliance. 09/16/2016 Implemented
SIN-00066729 Renewal 09/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for this home.The 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. self assessment was completed and sent to wszott@pa.gov 10/31/2014 Implemented
6400.76(a)The floor threshhold from the office to the enclosed patio had a high relief off the floor presenting a potential tripping hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. This tripping hazard was removed by our maintenance department. 10/02/2014 Implemented
6400.104The home's notification to the fire department did not include the bedroom location of an individual who requires assistance in case of an actual fire.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. A formal letter was sent to the Fire Marshall at Franconia Township indicating the specific need of our individuals served. 09/29/2014 Implemented
SIN-00053248 Renewal 09/23/2013 Compliant - Finalized