Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228550 Renewal 08/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.88(f)On 8/1/23, there were three fire extinguishers in the program areas that were most recently inspected and approved by a firesafety expert on July 2022.Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.On Thursday August 3, 2023, all fire extinguishers were serviced to bring them back into compliance. The Facility Director was notified immediately after the licensing and contacted the company to schedule the extinguishers to be serviced. 08/03/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 12/9/22 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. (Repeated Violation-5/18/22, et al).The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A meeting was held with the program specialists and Compliance Coordinator to review a newly created checklist that the designated CEO developed. All staff responsible for the collection and review of the physical information are aware of the checklist that needs to be used moving forward. 08/04/2023 Implemented
2380.181(e)(4)Individual #2's assessment, completed 3/2/23 did not include the individual's need for supervision. Individual #3's assessment, completed 12/6/22 did not include the individual's need for supervision.The assessment must include the following information: The individual¿s need for supervision.The assessment was updated to include a separate section that indicates the individual's need for supervision. The assessments were corrected on Friday August 4, 2023, in a meeting held by the designated CEO, the three program specialists and the Compliance Coordinator. 08/07/2023 Implemented
SIN-00205244 Renewal 05/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)The physical examination for individual #1 conducted on 09/16/21 did not include the physical limitations of the individual. This section of the form was left blank.The physical examination shall include: Physical limitations of the individual.The section on the physical form for Individual #1 that asks about physical limitations has been completed to specify the exact type of physical limitations the individual has. 05/23/2022 Implemented
2380.111(c)(10)The physical examination for individual #1 conducted on 09/16/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the form was left blank. The physical examination for individual #2 conducted on 05/28/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the form was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.This section of the physical form for Individual #1 has been completed indicating whether or not there is any medical information pertinent to diagnosis and treatment in case of an emergency. 05/23/2022 Implemented
2380.111(c)(11)The physical examination for individual #1 conducted on 09/16/21 did not include special instructions for an individual's diet. This section of the form was blank. Individual #1's Individual Support Plan (ISP), last updated 5/19/22, states that individual #1 does not chew food. Pureed food is provided at day program and when at home family can cut food into small, bite-size pieces.The physical examination shall include: Special instructions for an individual's diet.This section of the physical form has been completed indicating special instructions for the individual's diet which reflects a pureed diet and that the individuals does not chew. 05/23/2022 Implemented
SIN-00188029 Renewal 05/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(1)Program Specialist #1, date of hire 12/05/2019, has a master's degree but at the time of hire did not have work experience working directly with persons with disabilities.A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with persons with disabilities.The Program Specialist Job Description has been updated to reflect the qualifications as written in the regulations. When interviewing for the Program Specialist position, all resume's will be reviewed prior to scheduling an interview by the Recruitments Specialist and then by the Director of Residential and Education Programs to ensure that the candidate has the necessary requirements documented on their resume. Prior to hire; the candidate will be asked to provide a copy of said diploma. 06/01/2021 Implemented
2380.21(u)Individual #1's most recent signed copy of individual rights was completed 5/30/2018.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The individual will sign the new rights upon return to program. The Quality Compliance Coordinator will be responsible for ensuring that the new rights are signed. 06/04/2021 Implemented
SIN-00161690 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(b)The agency had a fire safety inspection on 4/19/18 and then again on 7/18/19.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.The facilities director is responsible for obtaining the annual fire safety inspection, he was unaware it had to be exactly within 365 days. He was retrained on the requirements for the inspections from 6400 regulations. Both the facilities director and the compliance coordinator set reminders in the computer for when the inspection is coming up next year to ensure compliance. [Within 30 days prior to 7/18/2020, the CEO or designee shall communicate with the facilities director and the compliance coordinator to ensure the fire safety inspection is scheduled or completed with written documentation to ensure timely completion of the fire safety inspection. Documentation of the communication and fire safety inspection shall be kept and available upon request by the Department. (DPOC by AES,HSLS on 9/12/19)] 09/13/2019 Implemented
SIN-00067226 Initial review 08/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.51One of the two exits from the facility has a 2 inch threshold which lands onto gravel. The facility plans to serve individuals with mobility needs.A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.Effective Thursday August 21, 2014, Massaro Corporation began the project to create new concrete entrances to the two accessible entrances and the two stair tower exit doors located at 1400 South Braddock Avenue. Thursday and Friday August 21st, and 22nd, the old concrete sidewalks were excavated. On Tuesday August 26, 2014 that phase was completed. On Wednesday August 27, 2014, the second and final phase of laying concrete began. New concrete pads will be created to provide for level transitions through the two main entrance/exit doors. The entrance pads will be 12 feet wide, and span both entrance doorways, allowing for safe access or evacuation of the Program space. Any slopes involved in the construction of these entrances will fall well within ADA guidelines. The entrance pads will connect to new concrete sidewalks that will run the length of the property to Braddock Avenue, and also to the adjacent road, allowing multiple evacuation options. The concrete entrances are anticipated to be complete by August 29, 2014. 08/29/2014 Implemented
SIN-00247949 Renewal 07/16/2024 Compliant - Finalized
SIN-00142029 Renewal 09/24/2018 Compliant - Finalized
SIN-00122376 Renewal 10/05/2017 Compliant - Finalized
SIN-00102836 Renewal 10/28/2016 Compliant - Finalized
SIN-00084453 Initial review 10/26/2015 Compliant - Finalized