INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 2, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia, Inc. Re-Entry House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 April 2, 2026, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times for the safety and well being of residents, employees and visitors. A discolored and bulging ceiling tile was observed in the staff hallway, outside the handicap accessible bathroom.
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Plan of Correction
The discolored and bulging ceiling tile in the staff hallway, located outside the handicap accessible bathroom (RM 122), was immediately removed and replaced. The area was inspected for evidence of active water intrusion or moisture damage above the ceiling. Maintenance staff assessed and addressed the source of the discoloration to prevent recurrence.
The Program Director will implement a formal monthly physical plant inspection checklist that includes all hallways, common areas, and facility grounds. Findings will be documented and submitted to the Program Director for review. Any maintenance concerns identified will be assigned a completion timeline not to exceed 72 hours for non-emergency items and same-day response for safety hazards. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on April 2, 2026, the facility failed to maintain each bathroom in a functional manner at all times. Bathroom # 211, located on the second floor, was observed to have one toilet not functioning. The lid was removed and there was no water in the tank or the toilet bowl. The toilet did not flush.
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Plan of Correction
The toilet in bathroom #211 has been replaced by Gaudenzia Maintenance department and is now in good working order.
The Program Director will implement a weekly resident and staff bathrooms. Inspections will be documented on a Bathroom Maintenance Log, which will include date, inspector name, findings, and corrective actions taken. Any non-functioning fixture will be immediately taken out of service and repaired within 24 hours or an alternative facility provided to residents. |