Inspection Reports for
Roxborough Home for Women

601 Leverington Avenue, Philadelphia, PA 19128, Philadelphia, PA, 19128

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19 Reports

2016–2025

Inspection Report — Dec 9, 2025

Complaint Investigation
Date: Dec 9, 2025

Visit Reason
The inspection was a partial, unannounced complaint investigation conducted due to a complaint received by the Pennsylvania Department of Human Services.

Complaint Details
The inspection was triggered by a complaint regarding medication administration and resident care issues, including missed medications and lack of assistance with ambulation.
Findings
Multiple medication-related deficiencies were identified including missed medication doses, improper medication storage, inaccurate medication labeling, incomplete medication records, failure to follow prescriber orders, and failure to report medication errors. Additionally, a resident did not receive required assistance with ambulation due to staffing issues.

Citations (8)
2600.16(c) Written Incident Report: The home failed to report missed multiple days of prescribed medications for two residents to the Department within 24 hours as required.
55 Pa. Code §2600.60(a) Staff/Support Plan: A resident did not receive assistance with ambulation as required by their assessment and support plan due to lack of available direct care staffing.
55 Pa. Code §2600.183(e) Medication Storage: Prescription and OTC medications were stored beyond manufacturer discard dates or without documented opening dates.
55 Pa. Code §2600.184(a) Resident’s Medications Labeled: A pharmacy label did not match the Medication Administration Record, risking medication error.
55 Pa. Code §2600.187(a) Medication Record: Insulin administration was not documented on the resident’s medication administration record.
55 Pa. Code §2600.187(d) Follow Prescriber’s Orders: Multiple residents did not receive prescribed medications due to unavailability in the home.
55 Pa. Code §2600.187(d) Follow Prescriber’s Orders: A resident was not administered a prescribed topical patch since a specified date.
55 Pa. Code §2600.188(b) Medication Error Reporting: Medication errors involving missed doses were not reported to prescribers as required.
Report Facts
Residents Served: 18 Total Daily Staff: 18 Waking Staff: 14 Resident Supplemental Security Income: 1 Residents Age 60 or Older: 18 Residents Diagnosed with Mental Illness: 11 Residents Diagnosed with Intellectual Disability: 1

Employees mentioned
NameTitleContext
PCA SupervisorNamed as responsible person for corrective actions and monitoring in multiple findings.

Inspection Report — Aug 14, 2025

Follow-Up
Date: Aug 14, 2025

Visit Reason
The inspection was conducted as a partial, unannounced incident review related to a complaint or incident at the facility on 08/14/2025.

Complaint Details
The visit was triggered by an incident involving a resident requesting an additional sandwich and being yelled at by staff, which led to a complaint investigation. The incident was not initially reported as required, and the resident was upset and embarrassed by the staff's behavior.
Findings
The inspection found multiple violations including failure to report suspected resident abuse, improper treatment of residents, incomplete criminal background checks for staff, improper food storage practices, untimely medical evaluations, incomplete resident contracts, denial of additional meal portions, and incomplete preadmission screening forms. Corrective actions and plans of correction were accepted with completion dates mostly by September 2025.

Citations (8)
Failure to immediately report suspected abuse of a resident and failure to comply with reporting requirements under the Older Adult Protective Services Act.
Resident was not treated with dignity and respect; staff yelled at resident and denied requested additional food.
Staff member began work without a completed criminal background check.
Unsealed and undated container of ice cream found in basement freezer, violating food safety requirements.
Medical evaluation for a resident was not completed within 60 days prior to admission or within 30 days after admission.
Resident-home contract did not indicate whether the home collects a portion of the resident's rent rebate benefit.
Resident was denied additional portions of meals and beverages at mealtimes, violating resident rights.
Preadmission screening form did not include a determination that the needs of the resident can be met by the services provided by the home.
Report Facts
Residents Served: 16 Staffing: 17 Waking Staff: 13 Resident Supplemental Security Income: 1 Residents Age 60 or Older: 16 Residents Diagnosed with Mental Illness: 11 Residents Diagnosed with Intellectual Disability: 1 Residents with Mobility Need: 1 Residents with Physical Disability: 0

Employees mentioned
NameTitleContext
Staff Member ANamed in findings related to resident abuse, treatment with dignity, and denial of additional meal portions; was removed from direct care, suspended, and terminated.
Staff Member BNamed in finding related to lack of completed criminal background check prior to employment; background check completed retroactively.
AdministratorInvolved in issuing apologies to residents, overseeing corrective actions, conducting audits, and responsible for compliance and training plans.
PCA SupervisorResponsible for conducting training sessions and monitoring staff-resident interactions.
Kitchen SupervisorResponsible for retraining kitchen staff, conducting daily food storage inspections, and overseeing food safety compliance.

Inspection Report — Nov 13, 2024

Renewal
Date: Nov 13, 2024

Visit Reason
The inspection was an unannounced full renewal inspection conducted on November 13, 2024, to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.

Findings
The inspection identified multiple deficiencies including failure to post the current license and influenza information, incomplete resident contracts, missing criminal background checks, sanitary issues, missing bedside furniture and lighting, improper food storage, repeated use of the same fire drill exit, inadequate smoking area signage, staff driving without valid licenses, and incomplete first aid kits. All deficiencies had plans of correction accepted and were implemented by June 10, 2025.

Citations (14)
The home's inspection summary report dated April 18, 2024, was not posted in a conspicuous and public place.
The home did not have the required influenza poster in a public place as required by the Influenza Awareness Act.
Resident #1's contract was not signed and reviewed by the resident until after admission.
Resident-home contracts for Residents #1 through #4 did not indicate whether the home collects a portion of the resident’s rent rebate benefit.
Staff person A did not have a completed criminal background check including an FBI check.
Trash can in staff restroom was uncovered and filled.
Resident #2 did not have a bedside table or shelf beside the resident.
Resident #2 did not have access to a source of light that can be turned on/off at bedside.
Opened and unsealed bag of frozen fish patties found in basement freezer.
Unlabeled, undated bag of frozen carrots and frozen fish patties found in basement freezer.
The enclosed porch exit route was the same exit used during multiple fire drills, not alternating exits as required.
No signage indicating the designated smoking area; cushions on benches in smoking area.
Staff person B transports residents but does not have a current driver's license.
First aid kit in the van used to transport residents did not include a breathing shield.
Report Facts
Residents Served: 15 Total Daily Staff: 15 Waking Staff: 11 Residents Diagnosed with Mental Illness: 13 Residents Diagnosed with Intellectual Disability: 3 Residents 60 Years or Older: 15 Residents Receiving Supplemental Security Income: 1

Employees mentioned
NameTitleContext
Staff person ADOHNamed in criminal background check deficiency
Staff person BNamed in driver's license deficiency for transporting residents

Inspection Report — Apr 18, 2024

Date: Apr 18, 2024

Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/18/2024.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Total Daily Staff: 15 Waking Staff: 11 Residents Served: 15 Residents 60 Years or Older: 14 Residents Diagnosed with Mental Illness: 4 Residents Diagnosed with Intellectual Disability: 1

Inspection Report — Nov 21, 2023

Complaint Investigation
Date: Nov 21, 2023

Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 11/21/2023 and an exit conference on 11/29/2023.

Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the partial unannounced inspection on 11/21/2023.
Findings
The facility was found to have multiple deficiencies including failure to report incidents, inadequate supervision and disciplinary actions for staff misconduct, privacy violations due to camera recordings, sanitary and infestation issues, obstructed egress, incomplete medical evaluations, and medication administration concerns. Plans of correction were accepted and implemented by 01/12/2024.

Citations (14)
Failure to develop and implement a plan of supervision for a staff member involved in an alleged abuse incident.
Failure to report multiple incidents including medication flushing, bullying, choking, and staff misconduct to the Department.
Failure to notify designated persons following a resident fall incident.
Violation of HIPAA due to video recording of a resident in a state of undress and improper handling of the video.
Staff member yelling, screaming, banging on table, and using foul language towards residents.
Privacy violation due to security cameras recording residents' bedroom doors.
Criminal background check for a staff member was completed after the start date of employment.
Unsanitary conditions including uncovered trash and recycling bins with presence of flies, and unclean resident room.
Evidence of infestation with flies in the second floor halls and resident room.
Obstructed egress in a resident room due to clutter and objects blocking the door and walkway.
Fire drill record did not accurately report resident non-compliance during evacuation.
Medical evaluations missing pertinent information including emergency diagnosis and immunization history.
Resident allowed to take loose medications out of the home without documentation of administration; lack of physician assessment for self-administration ability.
Preadmission screening form was completed after the resident's admission date.
Report Facts
Residents Served: 17 Total Daily Staff: 17 Waking Staff: 13 Residents 60 Years or Older: 16 Residents in Hospice: 0 Residents Receiving Supplemental Security Income: 0 Residents Diagnosed with Mental Illness: 0 Residents Diagnosed with Intellectual Disability: 0 Residents with Mobility Need: 0 Residents with Physical Disability: 0 Fire Drill Residents Present: 15 Fire Drill Evacuation Time (seconds): 232

Inspection Report — Sep 6, 2023

Renewal
Date: Sep 6, 2023

Visit Reason
The inspection was conducted as a renewal inspection of the Roxborough Home for Women facility to assess compliance with licensing requirements.

Findings
The inspection identified multiple deficiencies including failure to post influenza information, privacy policy issues, late criminal background checks for staff, staff qualification deficiencies, safety hazards on the exterior grounds, inadequate lighting in resident rooms, improper food storage and labeling, incomplete medical evaluations, smoking area safety issues, incomplete menu postings, medication administration by untrained staff, incomplete training records, and incomplete resident records. All deficiencies had plans of correction accepted and were implemented by November 27, 2023.

Citations (18)
Failure to post required influenza information in a public place year-round.
Admissions policy allowed room inspections at any time, violating resident privacy rights.
Criminal background checks for two staff members were completed late.
Direct care staff person A lacked a high school diploma, GED, or active nurse aide registry status.
Metal bench on exterior grounds was uneven and had a cushion blown off.
Resident #1 did not have access to a bedside lamp that can be turned on/off.
Kitchen refrigerator temperature was above 40°F at time of inspection.
Several unlabeled and undated food items found in refrigerator and walk-in freezer.
Resident #2's medical evaluation was incomplete and used outdated dates.
Resident #3's medical evaluation did not include medication regimen and related information.
Resident #4's medical evaluation did not reflect a significant change in medication self-administration ability.
Designated smoking areas lacked fire resistant furniture.
Menus were not posted for more than one week in advance.
Staff persons C and D administered medications without completing required medication administration training.
Medication administration training records for staff persons C and D lacked documentation of successful completion.
Resident #2’s preadmission screening form lacked determination that resident needs can be met by the home.
Resident #4's support plan was missing a page and did not identify need for medication assistance.
Resident #2's record lacked race, height, weight, hair and eye color, religious affiliation, identifying marks, recent photo, communication means, and medical insurance information.
Report Facts
Residents Served: 18 Staffing Hours: 18 Waking Staff: 14 Residents 60 Years or Older: 17 Residents Diagnosed with Mental Illness: 3 Residents Diagnosed with Intellectual Disability: 1

Inspection Report — Aug 15, 2022

Renewal
Date: Aug 15, 2022

Visit Reason
The inspection was conducted as a renewal review of the Roxborough Home for Women facility on 08/15/2022 and 08/16/2022 to verify compliance with licensing requirements and the implementation of the submitted plan of correction.

Findings
The inspection identified multiple deficiencies including failure to post the current license, lack of carbon monoxide detectors, incomplete criminal background check for the administrator, rodent infestation evidence, insufficient hot water temperature, incomplete first aid kit supplies, unlabeled and undated leftover food items, missing posted menus, incomplete past menu records, medication documentation errors, incomplete preadmission screening, and unsigned support plans. All deficiencies had plans of correction submitted and were implemented by 01/11/2023.

Citations (13)
The personal care home did not post the current license in a conspicuous and public place.
No carbon monoxide detectors were installed near fossil-fuel burning appliances.
The administrator did not have a completed criminal background check.
Rodent droppings were found on and around food storage cans indicating infestation.
An uncovered, unattended trash can was observed in the main kitchen.
Insufficient hot water temperature at bathroom sinks in residents' rooms.
The first aid kit in the medication room did not include bandages in a regular standard package.
Unlabeled and undated leftover food items were found in multiple refrigerators and freezers.
The weekly menu for one week in advance was not posted in a conspicuous and public place.
Past menus of meals served, including changes, were not kept from the previous month.
Glucometer readings for resident 3 were not documented in the MAR logs.
Resident 4’s preadmission screening form did not include a determination that the resident's needs can be met.
Resident 3 participated in the development of the support plan but did not sign it.
Report Facts
Inspection Dates: Inspection conducted on 08/15/2022 and 08/16/2022 Residents Served: 19 Staffing: 19 Waking Staff: 14

Notice — Sep 16, 2021

Date: Sep 16, 2021

Visit Reason
The document serves as a renewal notification and license issuance for Roxborough Home for Women, a Personal Care Home, and advises that an annual onsite inspection will be conducted within the next twelve months.

Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license following the renewal application.

Report Facts

Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notification letter.

Inspection Report — Jul 12, 2021

Renewal
Date: Jul 12, 2021

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 07/12/2021 to review compliance with licensing requirements for Roxborough Home for Women.

Findings
The inspection identified multiple deficiencies including privacy violations related to video camera signage, disrepair of bathroom ceilings, insufficient emergency food and water supplies, incomplete medical evaluations, outdated or discontinued medications, delayed resident assessments, and missing recent photographs in resident records. Plans of correction were accepted and documented for all deficiencies.

Citations (8)
Video cameras recording near exit doors without posted signs indicating recording.
Bathroom ceiling across from dining room in disrepair with holes and missing tiles exposing pipes.
Insufficient emergency drinking water supply (6 gallons onsite vs 54 gallons required) and no 3-day supply of nonperishable emergency food onsite.
Resident #1's medical evaluation incomplete; medication addendum missing.
Discontinued medication still present in resident #3's medication bin.
Resident #1's initial assessment not completed within 15 days of admission.
Resident #2's initial assessment not completed within required timeframe.
Resident #1 and #2's records missing photographs no more than 2 years old.
Report Facts
Residents Served: 18 Emergency Drinking Water Required: 54 Emergency Drinking Water Onsite: 6 Total Daily Staff: 18 Waking Staff: 14

Notice — Nov 5, 2020

Date: Nov 5, 2020

Visit Reason
The document serves as a renewal notification and license issuance for Roxborough Home for Women, a Personal Care Home, following receipt of their renewal application. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months.

Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.

Inspection Report — Aug 5, 2020

Follow-Up
Date: Aug 5, 2020

Visit Reason
The visit was a follow-up review of the submitted plan of correction for Roxborough Home for Women conducted over multiple dates to verify full implementation of corrective actions.

Findings
The submitted plan of correction was determined to be fully implemented. The facility addressed issues related to smoking policy violations and medication administration recordkeeping.

Citations (2)
144c1 Smoking Area Guidelines: The home permits smoking in a designated outdoor area but documented two occasions when a resident smoked outside the designated area.
187b Date/Time of Medication Admin.: Resident #1’s medication administration records lacked staff initials for multiple medications on several dates in July 2020.
Report Facts
Residents Served: 21 Staff: 21 Waking Staff: 16 Smoking violations: 2 Medication administration record omissions: 6

Inspection Report — Feb 27, 2020

Renewal
Date: Feb 27, 2020

Visit Reason
The inspection was a renewal visit conducted to assess compliance with licensing requirements for Roxborough Home for Women.

Findings
The inspection identified multiple violations including privacy concerns due to camera placement, incomplete criminal background checks, staff qualification issues, lack of annual training for the administrator, uncovered trash dumpster, food storage violations, incomplete medical evaluations, medication storage and documentation deficiencies, refusal of medication documentation issues, follow prescriber's orders violations, and incomplete resident record content.

Citations (13)
42s - Privacy: The home had cameras recording common areas but some cameras recorded exit/entrance doors, violating privacy rights.
51 - Criminal Background Check: A direct care worker started without a completed criminal background check for over a week.
54a - Direct Care Staff: A direct care staff person lacked a high school diploma, GED, or active nurse aide registry status.
64c - Annual Training: The home's administrator did not complete any Department-approved training hours in 2019.
85e - Trash Outside Home: The dumpster was uncovered on the day of inspection.
103c - Food Protected: An uncovered box of cookies was stored in the walk-in freezer basement.
141b1 - Annual Medical Evaluation: Resident #1's annual medical evaluation was more than 12 months overdue.
185a - Implement Storage Procedures: Resident glucometers were not calibrated correctly and blood sugar readings were missing from medication records.
187a - Medication Record: Resident #2's medication administration record lacked the name of the glucometer tracking sheet.
187b - Date/Time of Medication Admin: Resident #1 had a glucometer reading with no corresponding MAR entry; other residents had missing medication administration records.
187c - Refusal of Medication: Resident #1's medication refusal was not documented or reported to the prescriber as required.
187d - Follow Prescriber's Orders: Resident #1 was prescribed eye drops that were unavailable during the inspection period.
252 - Record Content: Resident #5's record lacked hair color, eye color, identifying marks, and a photograph.
Report Facts
Residents Served: 23 Staff Count: 25 Waking Staff: 19

Employees mentioned
NameTitleContext
Gabrielle AnikAdministratorNamed in multiple findings and plans of correction as responsible party.

Notice — Sep 5, 2019

Date: Sep 5, 2019

Visit Reason
This document serves as a renewal approval for the Roxborough Home for Women to operate as a Personal Care Home under Pennsylvania regulations.

Findings
The Department of Human Services confirms receipt of the renewal application and issues a regular license. It advises that an annual onsite inspection will be conducted within the next twelve months to ensure compliance.

Report Facts

Inspection Report — Mar 27, 2019

Annual Inspection
Date: Mar 27, 2019

Visit Reason
The inspection was an annual licensing inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.

Findings
The inspection identified multiple violations related to incident reporting, resident contracts, resident rights documentation, bedroom requirements, emergency supplies, medical evaluations, medication administration, and resident education. The facility submitted plans of correction and verification for all cited deficiencies.

Citations (14)
Regulation 2600.16(c): The home failed to report a resident incident involving a broken shoulder to the Department within 24 hours as required.
Regulation 2600.16(c): The home did not retain a copy of the incident report for a resident who was injured and hospitalized.
Regulation 2600.25(b): Contracts for residents #1 and #2 were not signed by the residents as required.
Regulation 2600.41(e): Resident #1 and #2 records lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Regulation 2600.101(j)(6): Resident #1's bedroom did not have a mirror as required.
Regulation 2600.107(c): The home had 20 residents but only 63 gallons of emergency drinking water, insufficient for a 3-day supply.
Regulation 2600.141(a)(2): Medical evaluations for residents #1 and #2 were incomplete or missing required attachments.
Regulation 2600.141(b)(1): Resident #3's annual medical evaluation was not completed or signed timely.
Regulation 2600.183(d): Resident #4's medication bin contained medications without current doctors' orders and test strips not belonging to the resident.
Regulation 2600.185(a): Resident #4's glucometer was not calibrated and did not have accurate memory dates for readings.
Regulation 2600.187(b): Resident #1's medication administration record documented medication given but lacked confirmation the resident actually received it.
Regulation 2600.187(d): Resident #1 was not administered prescribed medications on multiple dates as required.
Regulation 2600.191: Residents #1 and #2 were not educated on their right to question or refuse medication if they believed an error occurred.
Regulation 2600.224(a): Resident #1's pre-admission screening did not include a determination that the home could meet the resident's service needs.
Report Facts
Emergency Drinking Water: 63 Deficiency Count: 14

Notice — Sep 6, 2018

Date: Sep 6, 2018

Visit Reason
This document serves as a renewal notice and certificate of compliance for Roxborough Home for Women to operate as a Personal Care Home with a maximum capacity of 30 persons.

Findings
The Department of Human Services has approved the renewal application and issued a regular license. The Department will conduct an onsite annual inspection within the next twelve months as required by state regulations.

Report Facts

Inspection Report — Sep 18, 2017

Renewal
Date: Sep 18, 2017

Visit Reason
The document is a renewal application and license issuance for Roxborough Home for Women, confirming the renewal of their Personal Care Home license pursuant to Title 55, PA Code, Chapter 2600.

Findings
The Department of Human Services will conduct an onsite inspection of Roxborough Home for Women within the next twelve months as required by regulation. No findings or deficiencies are reported in this document.

Report Facts

Inspection Report — Aug 24, 2017

Annual Inspection
Date: Aug 24, 2017

Visit Reason
The inspection was an annual licensing inspection conducted on August 24, 2017, at Roxborough Home for Women. The visit was unannounced and included renewal and complaint reasons.

Findings
Multiple violations of the 55 Pa.Code Chapter 2600 were found, including missing carbon monoxide detector, unsafe freezer conditions, outdated food, late medical evaluations, failure to follow prescriber's orders, and incomplete documentation of support plan signatures. Plans of correction were submitted with varying implementation statuses.

Citations (6)
55 Pa.Code §2600: The home did not have a carbon monoxide detector outside of the basement heating room.
55 Pa.Code 2600.88(a): The floor of the walk-in freezer in the basement was covered with a thick sheet of ice posing a safety hazard.
55 Pa.Code 2600.103(l): Four dented cans and a bag of unlabeled croissants were found in the basement freezer.
55 Pa.Code 2600.141(b)(1): Resident #1's medical evaluation was completed late on 9/7/16; the previous evaluation was on 4/30/15.
55 Pa.Code 2600.187(d): The home failed to follow the prescriber's orders for resident #2's medications on multiple dates in August 2017.
55 Pa.Code 2600.227(b): Resident #3's support plan was complete on 5/4/17 but resident #4 did not sign the support plan and the home failed to document resident #3's inability or refusal to sign.
Report Facts
Resident Support: 18 Total Daily Staff: 36 Waking Staff: 27 Residents 60 Years or Older: 17 Residents with Intellectual Disability: 2 Current Hospice Residents: 1 Hospice Residents in Past Year: 2

Employees mentioned
NameTitleContext
Gabrielle AnikAdministratorSigned plans of correction for all violations
Sabrina FreemanOn-site inspector for the Department of Human Services

Notice — Oct 11, 2016

Date: Oct 11, 2016

Visit Reason
The document serves as a renewal notification for the Roxborough Home for Women Personal Care Home license and informs about the requirement for an annual onsite inspection within the next twelve months.

Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.

Report Facts

Inspection Report — Aug 23, 2016

Annual Inspection
Date: Aug 23, 2016

Visit Reason
The inspection was an annual licensing inspection conducted by the Pennsylvania Department of Human Services on August 23, 2016, for Roxborough Home for Women.

Findings
Violations of 55 Pa.Code Chapter 2600 were found related to fire safety inspection, medication administration records, and preadmission screening documentation. Plans of correction were submitted and partially implemented as of October 2016.

Citations (3)
55 Pa.Code 2600.132(b) - The last fire safety inspection and drill observed was conducted on 10/7/14, which is not within the required annual timeframe.
55 Pa.Code 2600.187(a) - Medication administration records did not accurately reflect the prescribed dosage for Docusate; the record stated 2 caps as needed but the order was for 1 cap as needed.
55 Pa.Code 2600.224(c) - The preadmission screening for resident #2 was missing required elements including name of admitting home, screening information sources, level of supervision, mobility needs, ability to self-administer, and determination if needs can be met by the home.
Report Facts
Number of Residents Served: 23 Total Daily Staff: 23 Waking Staff: 17

Employees mentioned
NameTitleContext
Gabrielle AnikAdministratorNamed as legal entity representative and administrator signing plans of correction

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