Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00295364 Renewal 10/05/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual # 2's Physical Examination signed by the physician on 12/04/25 does not include a review of medical history. The spaces were left blank.The physical examination shall include: A review of previous medical history.During a recent ISP meeting with Individual #2, Ray of Hope recommended that she has a physical within the next 45 days. The individual's physical examination will be reviewed by the CEO to ensure that it includes a review of previous medical history. 12/01/2026 Implemented
2380.111(c)(7)Individual # 2's Physical Examination signed by the physician on 12/04/25 does not include an assessment of the Individual's health maintenance needs. The spaces were left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.During a recent ISP meeting with Individual #2, Ray of Hope recommended that she has a physical within the next 45 days. The individual's physical examination will be reviewed by the CEO to ensure that it includes a review of the individual's health maintenance needs. 12/01/2026 Implemented
2380.111(c)(10)Individual # 2's physical examination signed by the physician on 12/04/25 does not include medical information pertinent to diagnosis and treatment in case of an emergency. The space is left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.During a recent ISP meeting with Individual #2, Ray of Hope recommended that she has a physical within the next 45 days. The individual's physical examination will be reviewed by the CEO to ensure that it includes medical information pertinent to diagnosis and treatment in case of an emergency. 12/01/2026 Implemented
2380.115(3)Individual # 3's Emergency Medical Plan which was included in the 05/27/26 right's packet did not include an Emergency Staffing Plan.The facility shall have a written emergency medical plan listing the following: An emergency staffing plan.Individual #3's written Emergency Medical Plan was updated with the emergency staffing plan. The Program Specialist will update all individuals' emergency medical plans to include the emergency staffing plan within the next 30 days. 11/13/2026 Implemented
2380.181(e)(7)Individual # 3's Assessment dated 04/24/26 does not identify his ability to sense heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The Program Specialist will review and update the individual's assessment to include documentation of the individual's knowledge of the dangers of heat sources exceeding 120°F that are not insulated and the individual's ability to sense and move away quickly from these heat sources. The Program Specialist will utilize key words such as sense and move away quickly in their assessments. The CEO will provide training to the Program Specialist regarding assessment requirements. 11/13/2026 Implemented
2380.21(l)Individual # 2's Quarterly CPS discussions which were held on 09/24/26 and 06/23/26 were not signed by the individual. Unable to verify the Individual's participation in the CPS discussion. Individual # 3's Quarterly CPS discussions which were held on 11/25/25, 02/20/26, 05/21/26 and 08/25/26, were not signed by the individual. Unable to verify the Individual's participation in the CPS discussion.An individual has the right to make choices and accept risks.The Program Specialist will ensure that all Community Participation discussions are reviewed for completeness and required signatures before being filed in the individuals record. The Program Specialists will be responsible for completing and maintaining the documentation and are trained on this requirement. 10/23/2026 Implemented
2380.182(a)Individual # 3's ISP last updated 06/30/26 indicates that he attends Ganister Station, however, Individual # 3 does not attend Ganister Station.The program specialist shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team.The Program Specialist will review the individual's Individual Plan and coordinate with the individual and the Individual Plan team to ensure the plan is revised with their involvement. The review and coordination will be documented and maintained in the individual's record. Within the next 7 weeks, the Program Specialists will review all individual's ISPs and make recommended revisions to the Supports Coordinators, if needed. 12/04/2026 Implemented
SIN-00274939 Renewal 10/06/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.57The right sconce light outside of the main entrance was not working during the physical site walk through.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.On October 9, 2025, the outside light was replaced immediately. Outside lights will be added to the monthly building inspections to ensure the outside lights are in working order. 10/09/2025 Implemented
2380.181(e)(5)Individual # 1's Assessment dated 05/02/25 does not assess the ability to self administer medications.The assessment must include the following information: The individual¿s ability to self-administer medications.Program Specialists will be educated to add more detail to the assessment to include the individual's progress toward self-administration of medications, as well as if the individual is or is not able to self-administer medications. 10/15/2025 Implemented
2380.181(e)(7)Individual # 1's Assessment dated 05/02/25 does not assess the ability to move away from heat sources. Individual #2's Assessment dated 3/19/2025 does not report if the individual can sense or have the ability to move away from heat source.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Program Specialists will be educated to add more detail about the individual's understanding of the danger of heat sources, ability to sense heat and the ability to move away from heat sources quickly. 10/15/2025 Implemented
2380.181(e)(8)Individual # 1's Assessment dated 05/02/25 does not assess the ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.Program Specialists will be educated to add more detail to the assessment to include the individual's ability to evacuate in the event of a fire. 10/15/2025 Implemented
SIN-00211022 Renewal 09/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.125(f)Individual #1 takes several psychotropic medications, however there was no SEEN plan as required by this regulation at the time of the inspection.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.A SEEEN plan was written and updated for individual #1 and sent to the SC to be added to his plan. Attachment #1 email to SC and individual #1 SEEN plan. 09/26/2022 Implemented
SIN-00194258 Renewal 10/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The last fire safety inspection was completed on 03/05/19. The agency was closed due to COVID during the following dates: 3/17/2020-7/08/2020, 10/05/2020-10/19/2020 and 11/23/2020-2/08/2021The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The CEO will be responsible to ensure the onsite fire safety inspection is completed yearly. Documentation will have the signature of the fire safety inspector, the date it was completed and results from the inspection. This will be kept with the individual fire safety trainings. 10/21/2021 Implemented
2380.115(2)Emergency medical plan for individual #1 states, "if a person is unable to drive or seek medical attention, the agency will provide a vehicle so that the person maybe assessed by a physician of the medical facilities above" This plan is ambiguous and does not indicate that 911 should be called, or who would be responsible for transporting the individual.The facility shall have a written emergency medical plan listing the following: The method of transportation to be used.CEO will be responsible for adding the method of transportation to all individual emergency medical plans. 10/22/2021 Implemented
2380.115(3)The emergency medical plan for individual #1 states that, "staff should ensure safety···". This does not constitute a completely constructed plan for the staff in the event of an emergency. Who should be notified? What staff are to stay at the facility? How many staff are to stay with the individual? Etc. This plan should detail what responsibilities staff will have in the event of an emergency.The facility shall have a written emergency medical plan listing the following: An emergency staffing plan.CEO will be responsible for adding a staffing emergency plan to all individual emergency medical plans. 10/22/2021 Implemented
2380.36(b)Staff #3 had fire safety training on 8/17/2020 and not again until 10/12/2021.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Agency Trainer will be responsible to ensure program specialists and direct service workers are trained annually by a fire safety expert on general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms and notification of the local fire department as soon as possible after a fire discovered. This training will be completed on or before their annual date. 11/02/2021 Implemented
Article X.1007Staff #2's Date of hire was 10/04/2021 but her criminal background check was not completed until 10/05/2021. According to OAPSA regulations, criminal background checks must be completed on or before the employee's first day of work.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The CEO will be responsible for the submission of the PA background check to the State Police for all prospective employees of the facility who have direct contact with individuals, 5 days prior to or on person's date of hire. 11/02/2021 Implemented
SIN-00176830 Renewal 09/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(c)Individual # 1's assessment dated 02/11/20 does not indicate that the assessment was completed based on instruments, progress notes and observations. Individual # 2's assessment dated 03/13/20 does not indicate that the assessment was completed based on instruments, progress notes and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations.Program Specialist will be responsible for adding how the assessment was completed using assessment instruments, interviews, progress notes and observations. An addendum will be added to each assessment that needs to address this. Target date for the completion will be November 18, 2020. The CEO will be implementing a monthly review to ensure this is being completed. 11/18/2020 Implemented
2380.181(e)(5)Individual # 2's assessment dated 03/13/20 does not assess his ability to self-medicate. The assessment reads "Staff in Individual # 2's group home give his medication before arriving at the ATF. He does not take any medication during ATF hours. If Individual # 2 were to need a med, the ATF nurse would administer it to him."The assessment must include the following information: The individual¿s ability to self-administer medications.The Program Specialist will be responsible for documenting the individual's ability to self-medicate. The Program Specialist will add this information to the addendum. The Program Specialist will collect this information from talking with the individual, as well as staff. The CEO will be implementing a monthly review to ensure this is being completed. 11/18/2020 Implemented
2380.181(e)(7)Individual # 1's assessment dated 02/11/20 does not indicate his ability to sense and move away from heat sources. The assessments reads, "Presently, Individual # 1 knows how to use the toaster and microwave. He requires line of sight supervision and partial assistance in the kitchen. He likes to bake cookies, so staff help with the oven." Individual # 2's assessment dated 03/13/20 does not indicate his ability to sense and move away from heat sources. The assessment reads, "Individual # 2 needs to be within arms' length supervision in the kitchen. He does not cook and can be impulsive."The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The Program Specialist will be responsible for documenting the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees Fahrenheit and are not insulated. The Program Specialist will add this information to the addendum. The Program Specialist will collect this information from talking with the individual, as well as staff. The CEO will be implementing a monthly review to ensure this is being completed. 11/18/2020 Implemented
2380.181(e)(8)Individual # 2's assessment dated 03/13/20 does not assess his ability to evacuate in the event of a fire. The assessment reads "During a fire drill, Individual # 2 walks with staff and peers outside to the designated meeting place at the ATF. On 01/22/20, he joined peers in watching the fire safety video".The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.The Program Specialist will be responsible for documenting the individual's ability to evacuate in the event of a fire in a safe and timely manner. The Program Specialist will add this information to the addendum. The Program Specialist will collect this information from talking with the individual, as well as staff. The CEO will be implementing a monthly review to ensure this is being completed. 11/18/2020 Implemented
SIN-00253524 Renewal 10/15/2024 Compliant - Finalized
SIN-00232227 Renewal 10/11/2023 Compliant - Finalized
SIN-00155570 Initial review 05/16/2019 Compliant - Finalized