Capacity 12. 6-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
After reviewing the documentation, I observed that seven out of the seven children's individual service plans reflected a supervision ratio of one caregiver per five children. These seven children were transported to school at a ratio of seven children to one caregiver. |
— |
| 3 | — |
748.941(b) - Training Criteria- Training on emergency behavior intervention and administering psychotropic medication must be instructor-led.
During the inspection, we observed four of four employee records reviewed lacked the instructor-led training for administering psychotropic medications.. |
— |
| 3 | — |
748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return
In reviewing the documentation, I observed that the Serious Incident Report does not include the time that Law Enforcement or the caseworker were notified. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
A caregiver violated the Operation's policy by taking children in care to unauthorized places (personal residence) without prior permission from the administration. |
Yes |
| 4 | — |
748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids
(4) out of (6) children in care were interviewed and reported that they saw one caregiver vaping while inside the facility, on the premises while providing care to children, and in the facility van while transporting children in care. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
In one of the records reviewed a staff was hired 9/15/22 but did not received the First-aid/CPR Training until 4/13/23. |
Yes |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
During the investigation inspection, EBI training certificates were reviewed and four staff members were delinquent on completing their EBI refresher trainings. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Staff yelling, threatening, cursing and egging on the children. Bouts of frustration and anger towards the kids. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the inspection, I observed that one resident bed had a damaged box spring with exposed spring and wood through torn fabric, This box spring was removed during the inspection and the child was relocated to another bed. |
Yes |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During the investigation, it was discovered the operation failed to provide a safe environment by placing a child with child sexual aggression history as a roommate to two children with sexual victimization history. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
There was no protective covering on one child's bed. Bedroom # 1 |
Yes |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the investigation inspection, there was an open package of sliced cheese and smoked sausages in the refrigerator, uncovered. |
Yes |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
In two of the records reviewed, there was no signature to indicated two professionals were included in the service plan meeting or team. |
— |
| 1 | — |
748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers
In two of the plans reviewed there was no signature provided to show that at least on caregiver was present and participated in the service plan meeting.. |
— |
| 5 | — |
748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting
It was alleged a caregiver threatened to have their children fight a child and another caregiver would jokingly threaten to use a 2x4 on children in care. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
There are allegations caregivers were conducting bedroom searches but those searches were not documented. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was alleged a caregiver tried to physically fight a child in care. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A staff member fell asleep for a few minutes while caring for children in care |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
During the investigation inspection it was learned that the medication was being administered in a separate container that was not the original container that the medication came in. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During the investigation inspection on 8/8/2024 and follow up inspection on 9/5/2024, a child?s bed was observed to have a broken slat. |
— |
| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
A staff member made multiple comments to a resident that made the resident feel uncomfortable and unsafe with the staff member. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
In reviewing the Serious Incident Report, I observed that the documented time of the incident was incorrect and that several locations requiring the documentation of date and time included the date but no documented time. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the investigation inspection, the mini refrigerator in the kitchen had a thermometer that read 50 degrees Fahrenheit, indicating the food in the refrigerator was not stored at the required 40 degrees Fahrenheit. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed a refrigerator unit used to store children's food without a thermometer. |
— |
| 3 | — |
748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies
One of the four serious incident reports reviewed failed to show that the caregiver attempted to de-escalate with the child before and during the restraint. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
During the investigation it was discovered that a child was permitted to go outside the cabin in an attempt to de-escalate what could have been a physical altercation with another child in care. During that time, the child was able to walk off the premises and allegedly found a pack of marijuana infused gummies, in which he later ingested, became ill, and needed to seek emergency medical care. Due to the circumstances surrounding the child's history with drug use and sexual behaviors and in addition to the CPS Child's Plan of Service, the operation failed to supervise the child adequately. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Due to staff not being aware, one child was put in a choke hold by another child. As a result, a canceled outing led to another child doing several thousand dollars worth of damage to the operation's property. |
— |
| 1 | — |
748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities
In the Initial Service Plan reviewed there was no signature documented for the person making decisions about the child's participation in childhood activities. Also there is no documentation where a current caregiver participated in the service planning. This is listed under a different standard number, but it is being cited underneath this standard. |
— |
| 2 | — |
748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children
Two of the four residents and all staff interviewed reported outings have been limited since the move to the new location. Two residents reported approximately one outing a week, while one staff stated there has not been any outings in a few weeks. |
— |
| 3 | — |
748.751(a)(2) - Pre-Employment Screening-You must contact the employer to verify if the applicant was employed as described in the applicant's employment history.
During the inspection, we observed one of four personnel records reviewed reflected employers within the past five years which were not included in the pre-employment screening steps. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
One child's record was missing documentation for the morning dose. |
— |
| 4 | — |
748.535(2) - Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on July 29, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees Fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees Fahrenheit. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
During the inspection, I observed the evacuation diagram in the cottage lacked a designated meeting place in case of fire evacuation, and they also lacked the designation of the shelter in place locaiton for inclement weather. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the investigation inspection, the black refrigerator in the kitchen had a thermometer that read 45 degrees fahrenheit, indicating the food in the refrigerator was not stored at the required 40 degrees fahrenheit. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The operation failed to submit quarterly EBI data timely. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection, I observed that one of the medication logs for the children showed administration of medications without a staff signature or the time of administration for 8 administrations. Through document review and interviews, I also observed that medications logs were not signed by the staff that administered the medications to the children. |
— |
| 5 | — |
748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment
A child in care was denied the right to attend church as a form of discipline. Although he had been asked to leave the previous evening, he had not been banned by the church. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Interviews during the investigation indicated that staff members use profane language around the children and in conversation with them. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, I observed a broken door to a bathroom closet on the first floor, a broken door to a stand alone storage cabinet in the laundry room, and the upstairs bedroom was cluttered and in need of cleaning. |
— |
| 4 | — |
748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification
One staff, whom the operation confirms is in ratio for child care, had a CPR / First Aid expired on 6/25/2021. |
— |
| 5 | — |
748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development
During the investigation, it was reported by three of the four children interviewed that the food at the operation is molded and expired. One child reported being given snacks in November 2024, that had an expiration date of March and July of 2024. The other two children reported there is molded and expired foods in the refrigerator. The protocol the staff and administrator report are being utilized to ensure there is no molded or expired foods is conflicting. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
Two beds did not have pillow cases. Both were corrected at inspection. |
Yes |
| 3 | — |
748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.
The employee file reviewed did not have a copy of the required reference checks required for employees hired after August 2023 |
— |
| 2 | — |
748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment
A resident reported and another corroborated that the administrator threatened loss of placement. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
During the investigation inspection, one child's medication record was not updated within 2 hours of staff administering the medication |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child at the operation was able to start a fire in nearby wooded area.. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Three of the residents beds did not have a matress cover |
— |
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
The Downstairs boys' bathroom did not have individual hand towels or disposable paper towels at the inspection. |
Yes |
| 2 | — |
748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility
The operation did not have a copy of the child's tuberculosis screening. The child has been living at the operation for over 40 days. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
Freezer reading was 21 instead of 0 degrees. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the investigation, it was discovered the operation failed to fill a child's prescription medication timely, resulting in the operation failing to administer medication to the child according to the instructions on the label. The cream was prescribed on 2/12/2024 and wasn't filled until 2/28/2024. The written orders were to apply topically daily. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the investigation, it was discerned a staff member used inappropriate language around and toward these children in care. |
— |
| 2 | — |
748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.
During the inspection, we observed two of four personnel records to include incomplete employment history verification checks or documentation as to why the employer was not reachable. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
A caregiver used profanity when talking to or about two teenagers in care. |
— |
| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
In the 15-passenger van two of the safety belts are in need of repair. One does latch but the front cover was missing. The other does not latch. These are both seats that would normally be occupied by residents. |
— |
| 5 | — |
748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision
Resident and staff indicated that they have observed a stff member sleep while on duty. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees fahrenheit. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During a walk through of the operation, several food items were noted to be expired by several years that were in can goods. |
Yes |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection it was learned that the person giving the medication to the children was not the person who was signing the medication log. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the inspection, it became evident a staff member was seen by other staff members transporting children despite having told other staff she was over tired. The staff in question also was discovered to have been making inappropriate comments and engaging in undesired physical contact with the boys. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
In the admission assessment reviewed there was no date documented on the assessment. Without the date documented it is not clear if the assessment was completed timely. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
There were hamburger buns with mold in the kitchen cabinet. |
Yes |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During a walk through of the operation, several food items were noted to be expired by several years that were in can goods. |
Yes |
| 3 | — |
748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies
One of the four serious incident reports reviewed failed to show that the caregiver attempted to de-escalate with the child before and during the restraint. |
— |
| 4 | — |
748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification
One staff, whom the operation confirms is in ratio for child care, had a CPR / First Aid expired on 6/25/2021. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection, I observed that one of the medication logs for the children showed administration of medications without a staff signature or the time of administration for 8 administrations. Through document review and interviews, I also observed that medications logs were not signed by the staff that administered the medications to the children. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the investigation inspection, the black refrigerator in the kitchen had a thermometer that read 45 degrees fahrenheit, indicating the food in the refrigerator was not stored at the required 40 degrees fahrenheit. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the investigation inspection, the mini refrigerator in the kitchen had a thermometer that read 50 degrees Fahrenheit, indicating the food in the refrigerator was not stored at the required 40 degrees Fahrenheit. |
— |
| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
A staff member made multiple comments to a resident that made the resident feel uncomfortable and unsafe with the staff member. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees fahrenheit. |
— |
| 3 | — |
748.751(a)(2) - Pre-Employment Screening-You must contact the employer to verify if the applicant was employed as described in the applicant's employment history.
During the inspection, we observed one of four personnel records reviewed reflected employers within the past five years which were not included in the pre-employment screening steps. |
— |
| 1 | — |
748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers
In two of the plans reviewed there was no signature provided to show that at least on caregiver was present and participated in the service plan meeting.. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was alleged a caregiver tried to physically fight a child in care. |
— |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
In two of the records reviewed, there was no signature to indicated two professionals were included in the service plan meeting or team. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
There were hamburger buns with mold in the kitchen cabinet. |
Yes |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed a refrigerator unit used to store children's food without a thermometer. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
In one of the records reviewed a staff was hired 9/15/22 but did not received the First-aid/CPR Training until 4/13/23. |
Yes |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
Two beds did not have pillow cases. Both were corrected at inspection. |
Yes |
| 3 | — |
748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return
In reviewing the documentation, I observed that the Serious Incident Report does not include the time that Law Enforcement or the caseworker were notified. |
— |
| 3 | — |
748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.
The employee file reviewed did not have a copy of the required reference checks required for employees hired after August 2023 |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Due to staff not being aware, one child was put in a choke hold by another child. As a result, a canceled outing led to another child doing several thousand dollars worth of damage to the operation's property. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
There are allegations caregivers were conducting bedroom searches but those searches were not documented. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During the investigation, it was discovered the operation failed to provide a safe environment by placing a child with child sexual aggression history as a roommate to two children with sexual victimization history. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees Fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees Fahrenheit. |
— |
| 2 | — |
748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility
The operation did not have a copy of the child's tuberculosis screening. The child has been living at the operation for over 40 days. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the investigation, it was discovered the operation failed to fill a child's prescription medication timely, resulting in the operation failing to administer medication to the child according to the instructions on the label. The cream was prescribed on 2/12/2024 and wasn't filled until 2/28/2024. The written orders were to apply topically daily. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
During the inspection, I observed the evacuation diagram in the cottage lacked a designated meeting place in case of fire evacuation, and they also lacked the designation of the shelter in place locaiton for inclement weather. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
In the admission assessment reviewed there was no date documented on the assessment. Without the date documented it is not clear if the assessment was completed timely. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
After reviewing the documentation, I observed that seven out of the seven children's individual service plans reflected a supervision ratio of one caregiver per five children. These seven children were transported to school at a ratio of seven children to one caregiver. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the investigation inspection, there was an open package of sliced cheese and smoked sausages in the refrigerator, uncovered. |
Yes |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the investigation, it was discerned a staff member used inappropriate language around and toward these children in care. |
— |
| 2 | — |
748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment
A resident reported and another corroborated that the administrator threatened loss of placement. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A staff member fell asleep for a few minutes while caring for children in care |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, I observed a broken door to a bathroom closet on the first floor, a broken door to a stand alone storage cabinet in the laundry room, and the upstairs bedroom was cluttered and in need of cleaning. |
— |
| 5 | — |
748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment
A child in care was denied the right to attend church as a form of discipline. Although he had been asked to leave the previous evening, he had not been banned by the church. |
— |
| 5 | — |
748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development
During the investigation, it was reported by three of the four children interviewed that the food at the operation is molded and expired. One child reported being given snacks in November 2024, that had an expiration date of March and July of 2024. The other two children reported there is molded and expired foods in the refrigerator. The protocol the staff and administrator report are being utilized to ensure there is no molded or expired foods is conflicting. |
— |
| 1 | — |
748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities
In the Initial Service Plan reviewed there was no signature documented for the person making decisions about the child's participation in childhood activities. Also there is no documentation where a current caregiver participated in the service planning. This is listed under a different standard number, but it is being cited underneath this standard. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
During the investigation it was discovered that a child was permitted to go outside the cabin in an attempt to de-escalate what could have been a physical altercation with another child in care. During that time, the child was able to walk off the premises and allegedly found a pack of marijuana infused gummies, in which he later ingested, became ill, and needed to seek emergency medical care. Due to the circumstances surrounding the child's history with drug use and sexual behaviors and in addition to the CPS Child's Plan of Service, the operation failed to supervise the child adequately. |
— |
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
The Downstairs boys' bathroom did not have individual hand towels or disposable paper towels at the inspection. |
Yes |
328 inspection record(s) on file from TX-HHSC.