Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279924 Renewal 12/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The door leading to the back deck of the home did not latch properly and would not stay shut.Floors, walls, ceilings and other surfaces shall be in good repair. The door could latch but has to be firmly pushed in to latch and stay closed. Maintenance readjusted the lock and it is latching. 02/20/2026 Implemented
6400.104The notification letter to the fire department does not include the general mobility of the individuals in the home.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. The letter indicated that individuals can evacuate without prompts. But it did not include physical mobility. We have reviewed all the letters and have added physical mobility. 02/20/2026 Implemented
6400.181(f)Individual #1's annual assessment dated 10/31/25 was not sent to the team at least 30 days prior to Individual #1's Individual Support Plan meeting on 11/25/25.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist did not send the assessment to the team in time before the individual ISP meeting was held. The PS will keep the past ISP review dates on file as the date on going. 02/20/2026 Implemented
6400.186Implementation of the plan. Individual #1 has a Restrictive Procedure Plan that states 1:1 staffing ratio from 8am to 12pm during the day at arm's length in the home and 1:2 from midnight to 8am hours/days seven day/week. If Individual 1 is asleep in her room, staff must remain in the room with the door open during the day and night hours. Overnight, staff will remain seated in the hallway outside her door to ensure constant auditory and visual monitoring. There is a second individual that resides in the home that also requires supervision. Individual #1's level of supervision in both the ISP and RPP contain conflicting information regarding overnight supervision and the location of staff. Current supervision levels cannot be maintained during overnight hours with another individual residing in the home and based on the conflicting information contained within the RPP and ISP.The home shall implement the individual plan, including revisions.The wordings of the RPP and the ISP were slightly conflicting in the implementation of the overnight(12am-8am) supervision level of care. The team met and was able to revise the plane and sent to the SC for correction. 02/20/2026 Implemented
6400.193(a)At the time of inspection all sharps were locked in the home despite there being only one individual in the home with a restrictive procedure plan in place with regard to sharp safety.A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program.Even though individual #2 did not have key, she could ask whenever she wanted to use sharps and the key was given to her. The fear was that individual #1 could get the key from individual #2 to access the sharps. It was suggested that we give a key to the individual that does not have RPP to enable her to have access to the sharp when she wants which we did. 02/20/2026 Implemented
6400.213(1)(i)213(1)(iv) Individual #1's individual record did not indicate the religion of the individual. The individual's record indicated that their religion was unknown.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The PS asked the individual about their religion and the individual said she does not know. Therefore, the PS indicated that the individual's religion was unknown. The PS has written that the individual does not know her religion. 02/20/2026 Implemented
Article X.1007The Provider is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was not a Pennsylvania resident for two continuous years prior to the start of employment and a FBI background check was not completed. Staff #1 was hired on 6/13/25 and was not a resident of Pennsylvania for the two years prior. Staff #1 did not complete a Federal Bureau of Investigation (FBI) criminal history record submitted to the FBI until 6/30/25.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The staff did her FBI check on 3/11/25 and she was hired on 6/13/25. She also did another FBI check with us on 6/30/25. The inspector might not have seen the 3/22/25 result in the record. The results are on file and will send copies. 02/20/2026 Implemented
SIN-00261984 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Based upon the expiration of the certificate of compliance the self-inspection of the home should have been completed between 9/4/24 and 1/4/25. The self-inspection submitted for review was completed on 2/5/25.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. This reg. is important to measure the record of compliance with the chapter When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 03/06/2025 Implemented
6400.21(e)At the time of inspection Individual #1 was the only Individual residing in the home and was admitted on 11/18/24. The date of birth provided by the agency for Individual #1 indicates that they were 17 years old at the time of inspection on 3/5/25. Staff #2 has a documented hire date of 9/30/24 and a first day with individuals date of 11/23/24. Records indicate that a child abuse clearance was not completed until 11/27/24. Staff #3 has a documented hire date of 1/2/25 and a first day with individuals date of 1/17/25. Records indicate that a child abuse clearance was not completed until 1/27/25.If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies.It is important to keep in compliance with this reg. to ensure the protection of the individuals. A child abuse clearance for Staff members were not completed before working with a child. Marion Reid clearance was done on 11/21/24 and her first home orientation was on 11/23/24. Staff Valerie Thomas clearance did not go through due to her putting in her personal information wrong and she had to redo the clearance. 03/07/2025 Implemented
6400.141(a)Records indicate that Individual #1 was admitted into the program on 11/18/24. The physical submitted for review was dated as completed on 12/3/24.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Regulation is important for the health and well-being of the individual. The individual physical was not done before moving into the CLA. The individual came from Kidz Peace, and their physical did not correspond with that of ODP reg. Our form was sent to the doctor to fill out the form, but it was never filled out and we had to do another physical. 03/21/2025 Implemented
6400.181(a)Records indicate that Individual #1 was admitted into the program on 11/18/24. The assessment presented for Individual #1 was dated as completed on 2/7/25, outside of the required 60 days. 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. Initial assessment is important for the individual¿s team to understand and know how to support the individual. During the inspection, the initial assessment was not done within the required time. The program specialist did the initial assessment within the 60 days period; however, the SC did not schedule the ISP in the 90 days¿ time frame. Therefore, the PS changed the initial date to reflect the ISP review date. 03/24/2025 Implemented
6400.52(c)(1)There was no documentation that Staff #1 had training on individual choice and supporting individuals to develop and maintain relationships during the provider established 2024 calendar training year as required.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.Training is important to maintain quality support for the individual. At the time of the inspection, Staff #1 did not have 2024 individual choice training. Staff #1 did all the required training as a manager with additional training. Individual choice and relationship are covered under the Individual Right and person center training which were done. 03/24/2025 Implemented