INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Samara House of CYWA, 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:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 residents, 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 conducted on January 22, 2018 between 2:00 pm and 3:00 pm, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as evidenced by the following:
1)The ceiling of the gym was damaged by water and falling down.
2)Flashing on the side of the building facing the adjacent building had fallen off and exposed the sub wood.
3)Exterior wall showed significant cracking from the top of the chimney to below the windows on the second floor.
4)Wooden flashing under the eve on the north side of the building was damaged, falling down and had holes through to the under roof.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Maintenance Coordinator for the CYWA who holds a Contractors License from the City of Coatesville has assessed all deficiencies and will be performing all necessary repairs.
The Board of Directors has assigned a property committee that will perform Semi Annual building inspections.
Maintenance Coordinator will perform quarterly building inspections.
The Executive Director, Director of D&A and Lead Counselor Aide will perform monthly building walk thru.
1.The maintenance coordinator determined the leak was caused by a/c condensation pump that went bad. Plan: To rent scaffolding to repair the ceiling: Quote for repair was received and approved to be completed 2/23/18.
2. The maintenance coordinator determined shingles failed due to weather. Plan; Maintenance staff has identified damaged area which will be re-shingled to be completed 2/23/18.
3. The maintenance coordinator assessed damage and determined crack was in stucco only not foundation crack. Plan:Maintenance staff will caulk and paint to be completed 2/23/18.
4. The maintenance coordinator assessed damage and determined the cause was due to age of bldg. Plan: Maintenance staff will replace the wood and paint to be completed 2/23/18. |