NEW YORK STATE

Eliot Spitzer OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE David A. Hansell

Governor 40 NORTH PEARL STREET Commissioner
ALBANY, NY 12243-0001

March 26, 2007

Mr. Roger Newman

Deputy Commissioner
NYC DHS/Family Services
33 Beaver Street, 16th Floor
New York, New York 10004

Dear Mr. Newman:

A complete inspection was conducted at the Auburn Family Residence on

February 5, 6, 15 and 16, 2007. Although the majority of the items were in
compliance with Part 900 of Title 18 NYCRR, several findings indicate non-
compliance with these regulations. Attached is the report of that inspection.

Any items of non-compliance must be corrected immediately and

notification of correction must be submitted detailing the corrective action
taken. Where this is impossible, a written plan must be submitted detailing
the corrective actions of all outstanding findings. The plan for corrective
action must be submitted to this office within 30 days of the receipt of this
report.

In the event that an endangering condition exists and OTDA has

found that the health, safety, or welfare of the public or any
individual is in imminent danger, OTDA may issue an “Order of
Correction” to correct such condition immediately or within any
specified period of less than 30 days.

If notification of the correction to the findings are not

received or the findings remain outstanding without an approved plan
for correction within the time period specified, OTDA may deny or
withhold reimbursement for allowable expenses as defined in Section
900.15(c) of Title 18 NYCRR.

Also attached to this report is the Inspector’s Comments and

Recommendations (ATTACHMENT A), General Maintenance Items (ATTACHMENT
B) and the Confidential Resident and Staff Findings (ATTACHMENT C)
noted during our inspection. The facility’s response to these
attachments must be included in the facility’s overall response to
this report.

"providing temporary assistance for permanent change"

COMMENTS:
Please note that we have cited several issues as a matter of concern
for priority correction; they are as follows:

Violation 10: Lack of Part 900 child-care for 85 unserviced resident

children between 3 months – 5 years.

Violation 17: Residents' complaints of cold rooms and 16 rooms were

taken off-line due to drafty windows (item noted for
FMD's attention).

Violation 19: Frequent elevator breakdowns requiring the FDNY to

respond to extricate residents (item noted for FMD's
attention).

If you have any questions regarding the information contained in the

attached inspection report or to request an electronic copy of this report,
please contact Sam Foriest at (212) 961-8234 or e-mail at:
sam.foriest@otda.state.ny.us.

Sincerely,

Jeff Barnes

Jeff Barnes
Director, Shelter Services

Enclosure

cc: Robert Skallerup, DHS-CO

James Russo, DHS-CO
Julia Moten, DHS-CO
Franca Okeya, DHS-CO
Yania Gonzalez, DHS-CO
Babatunde Salau, DHS-CO
Bethzaida Vazquez, Director, e-mail: Bvazquez@dhs.nyc.gov

JB/su

"providing temporary assistance for permanent change"

 OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

REPORT DATE: 03/26/07

REPORT OF INSPECTION

Facility Name: Auburn Family Residence

Street Address: 39 Auburn Place
City: Brooklyn, New York 11205

COUNTY: Kings

INSPECTION SCOPE INSPECTOR NAMES INSPECTION DATES

PROGRAM: Shirley Haines February 5, 6, 7 & 8, 2007

ENVIRONMENT: Carol Whaley February 15 & 16, 2007

"providing temporary assistance for permanent change"

 INSTRUCTIONS FOR SUBMITTING DEPARTMENT OF HOMELESS SERVICES (DHS)
FAMILY SHELTER INSPECTION RESPONSES
VIA E-MAIL OR HARD COPY

FOR DEPARTMENT OF HOMELESS SERVICES SHELTERS ONLY

• Once NYS OTDA completes a facility inspection report, a copy of the report
will be e-mailed to the facility’s Program Administrator at DHS and to the
facility with e-mail capability.

• A hard copy of the facility’s inspection report will also be mailed to the
facility.

• The facility’s response to the inspection report should be complete and

include responses to the Facility’s Findings, Inspector’s Comments and
Recommendations (Attachment A) and the Maintenance Deficiencies
(Attachment B).

The facility’s response to the inspection report should be addressed as

follows:

a) The facility’s response to the Facility’s Findings must be typed in

bold in the Facility’s Response Box located below OTDA’s Corrective
Action.
b) The facility’s response to the Inspector’s Recommendations (Attachment
A) must be typed in bold under each recommendation.
c) The facility’s response to Maintenance Deficiencies (Attachment B) must
be typed in bold after each maintenance item.
d) The facility’s response to the “Confidential Resident and Staff
Findings” (Attachment C) must be addressed according to the specific
individual and finding as noted on the attachment.

The facility’s hard copy response to the inspection report must be mailed to
their Program Administrator at DHS or e-mail the response to the Program
Administrator at bsalau@dhs.nyc.gov and rnewman@dhs.nyc.gov. (Note: All
facility responses to the inspection report must be forwarded to DHS for
their approval before they are forwarded to OTDA.)

• After the DHS Program Administrator has reviewed and approved the
facility’ response, a copy will be sent, via hard copy to Jeff Barnes,
Office of Temporary of Disability Assistance, Bureau of Shelter Services,
40 North Pearl Street, 9th Floor, Albany, New York 12243 or e-mail:
suzannah.ursprung@otda.state.ny.us.

• OTDA will review all facility responses for compliance and, if necessary,
request DHS and the facility to submit additional information.

"providing temporary assistance for permanent change"

 REPORT OF INSPECTION

REPORT DATE: 03/26/07

FACILITY NAME: Auburn Family Residence

VIOL REGULATION NUMBER

1 900.3(e)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
New York City Department of Homeless Services (DHS) failed to submit to the
Office of Temporary and Disability Assistance (OTDA) a request to renew the
approval of the facility’s Operational Plan. (Previously cited 11/15/01,
12/20/02, 01/09/04, 02/14/05 & 04/07/06)

CORRECTIVE ACTION:
DHS must submit a request to renew the approval of the facility’s Operational
Plan. The request must be submitted on OTDA’s current automated Part 900
Operational Plan CD format. A copy of the new OTDA Operational Plan CD format
was given to the facility during the inspection or an additional copy may be
requested by contacting OTDA.

DHS or Facility Response: (The facility must be specific and state the time period
when the deficiency will be corrected.)

VIOL REGULATION NUMBER

2 900.5(a)(7)&(b)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that all security officers have current state
certification cards on file. Although security officers’ license and
training profile was maintained, copies of FJC current security officers’
State certification was not on file for review. (Previously cited 04/07/06)

CORRECTIVE ACTION:
Facility administrative staff must ensure that all FJC Security officers have
current State certification and copies of current State certification cards
are to be available for review. Documentation of security officers’
certification and training must be maintained on premises at all times for
OTDA review and inspection. See OTDA approved Security Guards forms, Page
A12.1.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

"providing temporary assistance for permanent change"

VIOL REGULATION NUMBER
3 900.6(h)(1)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to obtain copies of all resident preliminary health
screen examination forms at the point of admission or within 24-hours after
admission to the facility. Eight of the twenty-five family case records
reviewed lacked copies of medical screen health forms. See Attachment C for
names. (Previously cited 02/14/05 & 04/07/06)

CORRECTIVE ACTION:
Social services staff must obtain and maintain a copy of all family
members’ preliminary health screen forms at the point of admission or
within 24-hours after admission to the facility. (Refer to OTDA
forms, page C50.)

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

4 900.6(h)(3)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to obtain copies of children’s inoculation history.
Seven of the twenty-five family case records reviewed lacked copies of the
children’s inoculation history. See Attachment C for names.

CORRECTIVE ACTION:
Social Services staff must request and obtain copies of children’s
inoculation history and file in family case record.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

5 900.10(c)(1)(i); 900.11(a) & 900.14(a)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to conduct a comprehensive assessment within 10 days of
the family’s admission date. Five of the twenty-five families’ case records
reviewed lacked a complete intake assessment and/or missing the following:
education or job/employment histories of all adult family members, summary of
assessed needs, reasons for family homelessness, ACS verification or results
of ACS inquiry. See Attachment C for names. (Previously cited 04/07/06)

"providing temporary assistance for permanent change"

CORRECTIVE ACTION:
Social Services staff must meet with all family members within two days of
their admission date to conduct, at a minimum, a preliminary needs intake
review, or a comprehensive assessment. In all cases, a comprehensive
assessment (including other adult family members) must be completed within 10
days of the family’s admission date and the Family Case Record Admission/
Assessment form is to be filled out in its entirety. See OTDA approved
forms, Pages C2.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

6 900.10(c)(1)(i)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to develop with the families a mutually agreed
upon service plan within ten days of the family’s admission. Four of
the twenty-five families’ case records reviewed lacked an initial
service plan agreement. See Attachment C for names.

CORRECTIVE ACTION:
Social Services staff must meet with families within ten days of the
families’ admission date to develop a mutually agreed upon services
plan designed to help the family to achieve permanent housing.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

7 900.10(c)(1)(ii)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to review and revise all families Bi-
Weekly/Independent Living Plans (ILP’s) on a bi-weekly basis. Six of
the twenty-five family case records reviewed lacked signatures of all
resident adults, omitted the other adult assessed needs on ILP’s or
the ILP was the same even when changes occurred with the family. See
Attachment C for names. (Previously cited 02/14/05 & 04/07/06)

"providing temporary assistance for permanent change"

CORRECTIVE ACTION:
Social Services staff must meet with all families, at a minimum, bi-
weekly to review and revise the Service and Bi-Weekly/Independent
Living Plan. All family members’ needs must be addressed on the plan
and signed by the adult members of the family. See OTDA approved
forms, page C7.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

8 900.10(c)(2)(ii)(a) & 900.14(a)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to document sufficient housing assistance for all
families. Four of the twenty-five family case records reviewed lacked
complete housing intake plans and or and housing notes. See Attachment C for
names. (Previously cited 02/14/05 & 04/07/06)

CORRECTIVE ACTION:
Social Services staff must ensure that all families housing intake plans are
completed within ten days of the families’ admission date and document
appropriate and concise housing notes at least monthly which is to be filed
in the housing section of the case record. Once a family is HSP certified,
additional housing notes are to be documented including problems that the
family may encounter which prevents them from obtaining permanent housing
timely.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

9 900.10(c)(2)(ii)(c)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to assist all eligible adult residents to engage in some
type of self-help initiative such as employment, job training or education
programs. At the time of inspection, there were 227 adult residents residing
in the facility, of which 155 were eligible to participate in self-help
initiatives. Only 36 of the 155 eligible adults or twenty-three percent
(23%) were actively participating in self-help initiatives. (Previously
cited 12/20/02, 01/09/04, 02/14/05 & 04/07/06)

"providing temporary assistance for permanent change"

CORRECTIVE ACTION:
Social Services staff must assist all eligible adult residents to participate
in self-help initiatives that will enhance the families’ ability to obtain
and retain permanent housing. Adult residents with special needs, which
exempt them from participation in self-sufficiency activities, must have
these needs thoroughly documented in the family’s case record. (Please refer
to OTDA approved Family Activity Forms pages P29 through P31.)

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

10 900.10(c)(5)(i)&(ii)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to provide structured child-care services for resident
children between the ages of 3 months through 5 years. On the day of the
inspection, there were 98 resident children between 3 months – 5 years. Of
the 98, 13 attended child-care off-site, and the remaining 85 were without
child-care.

CORRECTIVE ACTION:
The administrative staff must ensure that child-care is provided to
accommodate all families who are engaged in welfare-to-work initiatives such
as: employment, job training, attending an educational program, looking for
housing or for short-term emergency care. DHS must assign and designate
appropriate rooms for child-care as well as hiring appropriate staff.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

11 900.11(a)(1) & 900.14(a)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to monitor families signing in and out on a daily basis.
Resident’s Pass Control In/Out form does not adequately reflect residents’
activity of entering and exiting the facility. (Previously cited 01/09/04,
02/14/05 & 04/07/06)

CORRECTIVE ACTION:
The facility’s administrative staff must institute a procedure assigning each
family a Sign In/Out form by room numbers which is to include the names of
the adults and family composition on each form. All adult family members
must sign as they enter and exit the facility. Each entry is to be initialed
or signed by facility staff or security officers after they verify residents’
entering or exiting the facility. The Sign In/Out forms are to be reviewed

"providing temporary assistance for permanent change"

daily; and families’ presence, absence, approved passes or curfew violation
is to be indicated on the daily census form. See next finding #12 below.
(See OTDA approved form Page A-6)

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

12 900.11(a)(1) & 900.14(a)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to maintain a daily census of all its residents.
(Previously cited 01/09/04, 02/14/05 & 04/07/06)

CORRECTIVE ACTION:
The facility’s administrative staff must maintain an accurate daily census of
all its residents which indicates the presence and absence of all adult
family members from the facility on a daily basis. The census document must
clearly distinguish all adult absences, approved absences, discharges, curfew
violations and total billing days per family per month in which
reimbursements are claimed. Information of residents’ presence or absence is
to come from the Residents’ Sign In/Out logs. See finding #11 above. (See
OTDA approved form Page A-5)

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

13 900.11(a)(2) & 900.15(c)(4)(iv)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to maintain an accurate school-age master roster of
school-age children’s daily departure for school.

CORRECTIVE ACTION:
The facility’s staff designee must ensure that procedures are in place to
monitor and document all children of school age daily departure for school.
See OTDA approved School age Master forms, pages P43 – P45.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

14 900.11(a)(3)

"providing temporary assistance for permanent change"

SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that adequate and appropriate electronic
surveillance equipment was installed to view the grounds, facility, and
activities of the residents in order to lessen the risk of resident injury,
prevention of theft and prevention of unauthorized persons from entering the
facility. (Previously cited 11/15/01, 12/20/02, 01/09/04, 02/14/05 &
04/07/06)

CORRECTIVE ACTION:
The facility must install an electronic security surveillance system that
will cover the entrance door, perimeter of the building and lobby of first
floor. The surveillance system must have recording capabilities and the
system must also allow for playback while the system continues to record. If
the system is not digital, storage space must be available for the tapes to
be securely stored for a minimum of 14 days.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

15 900.5(a)(2)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that the stairwell “A” fire hose was protected
against vandalism. The fire hoses on the 1st and 4th floors were unraveled.

CORRECTIVE ACTION:
The facility must install fire department approved fire hose enclosures for
all fire hoses.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

16 900.5(a)(3); 900.12(b)(6)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility must ensure that all resident showers are adequately operating.
Showers on the 3rd floor provided only cold water.

"providing temporary assistance for permanent change"

CORRECTIVE ACTION:
The facility must ensure that adequate hot water for bathing is provided at
all times.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

17 900.5(a)(4); 900.12(a)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
At the time of inspection, 16 rooms were off-line due to the lack of heat due
in part to drafty non-storm windows. (Previously cited 01/09/04, 02/14/05,
04/07/06)

CORRECTIVE ACTION:
Although the facility provided plastic window covering to residents, the
attempted insulation of the windows was not sufficient enough to stop cold
air drafts. According to staff, plans to replace the windows have been
approved, please state the date the replacement windows will commence.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

18 900.5(a)(1)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility plans to have major exterior brick work done to the facility in
the spring of 2007.

CORRECTIVE ACTION:
The facility must submit a beginning date for the commencement of the
exterior brick work and project a completion date.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

"providing temporary assistance for permanent change"

VIOL REGULATION NUMBER
19 900.5(a)(6)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that the elevator was in a good state of repair
at all times. Based on records, the New York City Fire Department responds
weekly to person(s) stuck in the elevator. The elevator is put back in
service without inspection and safety certification from the elevator
maintenance company.

CORRECTIVE ACTION:
The facility must ensure that the elevator is repaired and certified prior to
placing it back in service. Please submit a copy of the most recent elevator
inspection and certification with this report.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

20 900.5(a)(6)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure the following maintenance repairs were
done:
a. The following missing store room doors were being replaced:
Storeroom door 273 and door 632.
b. Smoke door (near 360) not closing all the way.
c. Kitchen door to corridor was off-line.
d. The 4th floor stair “A” door was off-line and had a 3 inch dent at the
top of the door.

CORRECTIVE ACTION:
The facility must repair all doors as stated above in items a, b, c and d.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)
a-
b-
c-
d-

"providing temporary assistance for permanent change"

VIOL REGULATION NUMBER
21 900.11(a)(8)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that a staff member on each shift was qualified
in Standard First Aid.

CORRECTIVE ACTION:
The facility must ensure that at least one staff member on each tour, 24
hours per day 7 days per week have a minimum of eight hours of basic first
aid training or be a nurse.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

22 900.12(b)(4)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to provide the resident tub rooms with the following:
a. A tub curtain and/or rod to afford the clients privacy.
b. An enclosed private dressing area at or near the tubs and showers.

CORRECTIVE ACTION:
a & b. Private dressing space must be provided at all the communal tubs and
shower stalls.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

VIOL REGULATION NUMBER

23 900.12(e)(8)
SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED:

FINDING:
The facility failed to ensure that all resident sleeping areas have shades or
other appropriate window covering to ensure privacy. Approximately 90% of
the resident bedrooms were without such provisions. (Previously cited
10/03/94, 06/13/95, 07/18/96, 03/28/97, 04/14/99, 11/15/01, 12/20/02,
01/09/04, 02/14/05, 04/07/06)

CORRECTIVE ACTION:
The facility must provide privacy shades or a window covering for all
apartment windows.

"providing temporary assistance for permanent change"

Facility Response: (The facility must be specific and state the time period when the deficiency
will be corrected.)

"providing temporary assistance for permanent change"

 ATTACHMENT A

Inspector’s Recommendations and/or Comments

Employed Families
Employed families ineligible for HSP or other housing subsidies must also
develop a service plan/independent living plan, which describes in detail the
following procedures:

• A plan to search for housing, including the completion of a weekly housing

search sheet which advise the specialist of the family’s housing search
progress and other housing issues as necessary;
• Agreement to an amount of funds to be saved for broker’s fees, first
month’s rent, security deposit and other necessary expenses;
• Agreement to a time frame for saving the necessary fees and deposits; and,
• Providing proof to the specialist on a weekly basis of such savings.

Families who are non-compliant must be referred to the appropriate supervisor

for the sanctioning process to begin.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

"providing temporary assistance for permanent change"

 ATTACHMENT B

MAINTENANCE DEFICIENCIES

PLEASE TYPE YOUR CORRECTIVE ACTION RESPONSE IN BOLD UNDERNEATH EACH ITEM

1) Complaints of roaches: Rooms 723, 720, 714, 646-4, 642-3, 635, 552,
529, 450-6, 455-1, 356.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

2) Excessive belongings were stored in the room and/or garbage, food,

clothes was strewn about the floor: Rooms 275, 524, 703 and 825. The
families in these units may require intervention for ADL skills by
social services personnel.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

3) a- The following rooms had windows that failed to close flush to the
frame Room 715.
b- Room 646-3 window was open and not fitted with a screen or guard
rail.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

4) Rodent problem: Rooms (rodent entry holes): 827, 624-3, 635, 646-1,
466-4, 352, 358 and 370-1.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

5) Unit radiator cover was detached from the radiator: Room 361-4.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

6) Toilet (stall) door missing: Bathrooms 279 and 370-1.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

"providing temporary assistance for permanent change"

7) Dresser drawer is missing and/or broken: Rooms 280-2, 256, 3-367,
450-4, 626-5, 624-4, 624-3, 703, 745, 742 and 8-222.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

8) a- Bathroom 4-462A wall pipe access door was missing (next to

tub); the pipe chase is accessible to children.
b- The tub in 4-462A could not be used; the overflow drain was
covered with tape.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

9) a- The bathroom ceiling exhibited a black mold like growth: 3rd floor
handicap bathroom.
b- The lower bathroom (opposite 626) window pane was not frosted to
provide privacy.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

10) a- Padlocks or sliding bolts were attached to the storeroom and utility
room corridor side doors. These locks are not the safety locks which
would allow an individual locked inside the room to exit when the
outside lock is engaged.
b- The utility doors and storeroom doors were not labeled or
differentiated from other corridor doors.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

11) Stairwell “B” door hangs and trash bags were used to maintain the door
in the open position; also, the same condition existed at the 5th floor
door “A” and stair “A” 1st floor.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

12) Floor tiles were missing: Rooms 825 and 614.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

"providing temporary assistance for permanent change"

13) There were holes in the 3rd floor security locker room ceiling, plus
ceiling tiles were missing.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

14) Emergency entry/exit into Room 526 was blocked by a dresser near the
door.
Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

15) There was a foul odor in room 454.

Facility Response: (The facility must be specific and state the time period when the
deficiency will be corrected.)

CORRECTIVE ACTION:
Clean, repair, replace and/or restore the above items/make the appropriate
intervention and referrals.

"providing temporary assistance for permanent change"

 ATTACHMENT C
CONFIDENTIAL RESIDENT AND STAFF FINDINGS

This Attachment is for the purpose of identifying specific residents so that

the findings noted on report may be corrected. It should be kept
confidential.

FAMILY SHELTER NAME: Auburn Family Residence

DATE(S) OF INSPECTION: February 5 – 8, 2007
INSPECTOR(S) NAME: Shirley Haines

FINDING REGULATION DESCRIPTION RESIDENT NAME/

NUMBERS NUMBERS EMPLOYEE NAME*
3 900.6(h)(1) Missing preliminary health
forms.

4 900.6(h)(3) Missing copies of children’s

inoculation history.

5 900.10(c)(1)(i); Incomplete intake assessments

900.11(a)(6) & on families.
900.14(a)

6 900.10(c)(1)(i) Initial service plan (SP/ILP)

not developed within ten days
of admission.

7 900.10(c)(1)(ii) Review of SP/ILP’s not

consistently done or only
adult signed the plan.

8 900.10(c)(2)(ii) Housing Intake plans not

(a)& 900.14(a) completed within ten days or
missing housing notes.

"providing temporary assistance for permanent change"