Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243988 Unannounced Monitoring 04/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34Physical site review: 7800 Lindbergh Blvd., Apt. 113 The unannounced inspection was not conducted due to access. Spoke with Operations Manager. The manager stated the individual was not home. The manager stated the individual was at day program so no DSP staff were present in the home. The manager was asked if someone could come to the home and grant access so the inspection could be conducted and the manager said no one would be able to arrive to the home until 4pm, when the individual is schedule to arrive home from day program. The manager was asked if someone from the agency could come to the home and grant access. The manager reiterated her original answer as the final answer. The agency was not willing to send someone to open the home.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.This was an unannounced visit on a Friday when a lot of administrative employees were out of the office on vacation or sick leave. The plan of correction is to have a member of management available to grant access to the home 05/01/2024 Implemented
SIN-00211863 Renewal 09/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill has not been held in more than a year, based on the fire drill history provided that dates back to March 2021A fire drill shall be held during sleeping hours at least every 6 months. A new fire drill plan that includes sleeping hours was created and distributed across the homes 09/28/2022 Implemented
SIN-00219026 Renewal 09/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill has not been held in more than a year, based on the fire drill history provided that dates back to March 2021A fire drill shall be held during sleeping hours at least every 6 months. A new fire drill was conducted during asleep hours on October 13, 2022. A new schedule was put in place om the company calendar to ensure this occurs company wide once every 6 months 10/13/2022 Implemented
6400.24Several new hires did not have a criminal background check, FBI check, or residency waiver in record at time of inspection. staff 1-no cbc/fbi staff 2-no cbc/fbi staff 3-no fbi/residency waiver staff 4-no cbc/fbi staff 5-no cbc/fbi staff 6-no cbc/fbi staff 7-no cbc/fbi staff 8-no cbc/fbi staff 9-no cbc/fbiThe home shall comply with applicable Federal and State statutes and regulations and local ordinances.Background checks were completed for the aforementioned staff and FBI checks were completed for any staff who had not been a resident of PA for more than 2 years. 10/13/2022 Implemented
SIN-00177086 Renewal 09/23/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Water temperature measured at approximately 138.2 degrees Fahrenheit in the bathroom tub during inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water heater was adjusted on 09/24/2020 and measured again to ensure compliance. Ongoing monitoring will continue ongoing monitoring via monthly 6400 checks to ensure water temperature is within limit 09/24/2020 Implemented
6400.82(e)There was no non-slip mat located in the shower of the bathroom at the time of inspection. Bathtubs and showers shall have a nonslip surface or mat. A non-slip mat was purchased on October 5 and installed in the apartment on October 5, 2020 and installed. Ongoing monitoring will continue ongoing monitoring via monthly 6400 checks to ensure the non-slip mats are always in the bath tub and not removed by individuals whether intentionally or not 10/05/2020 Implemented
SIN-00149162 Renewal 01/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The Hot water temperature was 125.3°F in the bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. This location is currently licensed, but is not occupied. The CEO verbally issued a request for repair/adjustment of water temperature to the maintenance department of the landlord on 01/25/2019 to adjust the hot water temperature. Provider did not receive confirmation of work being completed by the landlord. CEO issued a written request to the landlord to remedy the issue, if not already done. Provider received a confirmation on 03/12/2019 that the work had been completed. See Exhibit 17 While the home is currently unoccupied the company procedure and instructions to any staff would be as follows: While waiting for confirmation of repair, the Provider has a water temperature thermometer to check water temperature at the locations. Staff was instructed to ensure that bathwater was at a comfortable temperature for the individuals and that they did not enter the bath/shower until the water was run and the temperature did not feel too warm/was at a comfortable temperature for the individuals. To prevent recurrence, the CLA Site Supervisor will oversee compliance in this area during weekly site visits for monitoring purposes and record the water temperature on the CLA House Inspection checklist by testing the water temperature to ensure hot water is not exceeding 120 degrees F. The checklist will be submitted to the Program Specialist. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. A water temperature above 120 degrees F will be reported immediately to the landlord in writing for repair or adjustment of the water heater. The CLA Site Supervisor will follow up with the landlord on a consistent basis to ensure that the repair is done in a timely manner. While waiting for confirmation of repair, the Provider will instruct staff to use the water temperature thermometer to check water temperature at the location. This is to ensure that bathwater is at a comfortable temperature for the individuals and that they individuals do not enter the bath/shower until the water has run and the temperature does not feel too warm/is at a comfortable temperature for the individuals. In addition, should any staff feel that site water feels too warm; they will also test the water temperature. Should a water temperature reading exceed 120 degrees F, staff will immediately report this to the CLA Site Supervisor. 03/12/2019 Implemented
6400.71There were no telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center near the telephone in the unit.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers were located in the home, but were not posted by the fixed telephone in the living room. The posting was placed by house phone located in the living room by the Program Specialist on 01/25/2019. A new posting was created with more visual effect on 03/11/2019 and replaced the original posting in all locations. The CLA Site Supervisor will monitor to ensure that postings of emergency numbers are at each fixed telephone and document on the weekly CLA House Inspection checklist, which will be submitted to the Program Specialist. If the emergency number posting is missing it will be replaced immediately. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. All current staff have been retrained on the regulation that emergency numbers must be in place by the fixed house telephone. If the number list is missing it must reported to their supervisor immediately up discovery so it can be replaced. All incoming staff will be trained on the location of the emergency numbers as part of their initial CLA orientation. All current staff have been retrained on the location of the telephone numbers. 01/25/2019 Implemented