INITIAL COMMENTS
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This report is a result of an on-site inspection conducted on April 11, 2011 to determine the appropriateness of granting a capacity increase request. The inspection was conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen Clear Child Services, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on May 12, 2011.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection during the 4/11/2011 licensing review, the facility failed to ensure that the grounds of the facility were clean safe and sanitary at all times and that the exterior of the building grounds was free of hazards.
The findings included:
The building was inspected on 4/11/2011 at approximately 12:00 noon . The Southeast corner of the building is very close to an embankment that is covered with brush and trash and drops into a nearby creek. The area was not clean during the inspection and the drop off on the embankment created a safety hazard. No barrier was observed to prevent children from playing in that area. This embankment is also accessible from the southwest corner of the building and no barrier was noted on that side.
The findings were reviewed with administrative staff and were not disputed.
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Plan of Correction
Pauline Rabb, Building administrator has instructed our maintinance department to erect a six foot fence across the back side of the building and the property line within the next 60 days. Facility Director will be responsible to make sure the fence has been erected within the 60 days. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the inspection of the physical plant and the fire drill log during the onsite inspection of 4/11/11, the facility failed to document the time of each fire drill as required, for five of five fire drills conducted since moving to the facility.
The findings included:
Fire drill log entries were reviewed for the period since the facility moved to the current location. Five fire drills have been held to date. They occurred on : 11/20/10, 12/13/10, 1/17/11, 2/112/11 and 3/31/11. Each of these five fire drills failed to document the time of day that the drill was conducted.
The findings were reviewed with administrative staff and were not disputed.
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Plan of Correction
Facility Director added a seperate column to the current fire drill form and has discussed with all staff. |