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Safe Haven Youth Ranch

Child care center · 28158 SH 6, Hempstead, TX 77445 · License 1692813

0Compliance score
Poor

Capacity 32. 10-17

Violation history (500)

Severity	Date	Standard / narrative	Corrected
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Staff described physically picking up a child in care and placing him in his bedroom after an altercation with another child.	—
4	—	748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted. There were three serious incidents involving one child in care exhibiting suicidal ideations. There were no documented suicide screenings for neither incident.	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity A child was inappropriately touched by another child while outside and under the supervision of staff.	—
3	—	748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for A child in care was reported to have been on a one-to-one level of supervision, yet there are multiple incidents where the same child was involved in horseplay with a second child in care. These same incidents were documented and required further investigation.	—
2	—	748.361(d) - Personnel records-The system for maintaining all records must be uniform throughout the operation Records were supplied in two formats: electronic and paper. However, the documents in both formats lacked uniformity, which created challenges in processing the information. Additionally, there were several missing documents in both the electronic and paper submissions, further complicating the review and analysis of the records.	—
3	—	748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059 One of four employee files reviewed was observed to be missing notarization on the Licensing Affidavit for Applicants for Employment form.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model A medication log for a child in care indicated a remaining count of 30 pills; however, a physical count revealed only 16 pills.	—
2	—	748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan A Service Plan Review was observed to be completed past 90 days of the Initial Service Plan completion date.	—
3	—	748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented There is no documentation showing that the smoke detector was tested in October 2025 in the Brazos House, and none from July through December 2025 in the Llano House.	—
3	—	748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline The reportable incident occurred on 10.15.22 and it was not reported by the operation to licensing until 10.19.22	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language A staff member directed profanity towards a child in care as a means of discipline.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Admissions Assessments for two children in care were observed to be missing pertinent information.	—
4	—	748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions During the inspection it was observed that the operation had expired food in the pantry and not stored properly. There were two open food boxes in the pantry..mash potatoes, pancakes (photos taken).	—
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. It was observed in one of four employee files reviewed that the operation did not contact each employer included in the five-year employment history.	—
3	—	748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record One Child's Right's form was observed to be missing the child's signature.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records One of four child's records reviewed had a different child's name listed in file.Additionally, one of the employee records reviewed lacked documentation of a drug tests being taken	—
4	—	748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services One of four records revewed observed EBI was not completed; last completion was 07/23/2024.	—
1	—	748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event Documentation related to the medical records of a child admitted in June 2024 was not observed in the child's file.	—
5	—	748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work. A child in care was slapped in the face by a staff member as a means of punishment.	—
4	—	748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards During the walk through it was observed that one building had a door with a board over the window. Photos taken.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment It was determined a staff member made inappropriate comments to a child in care regarding family and also engaged in an unnecessary power struggle with a child in care.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication Two medication logs for one child in care were observed to be missing signatures of the staff member who administered the medications on 04/14/26, 04/16/26, and 04/17/26.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed 2 children in care were given one extra dosage of medication.	—
2	—	748.1205(a)(8) - Admission Documentation-Includes allergies (food, medication, sting, and skin allergies) Admission Assessments does not include known allergies.	—
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 Staff and residents interviewed stated a staff member called a resident a derogatory name.	—
4	—	748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs During the course of the investigation, it was found that the medication error happened on 1-9-23 and it was not documented until 1-20-23.	—
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. An employee file was observed to lack documentation related to pre-employment screening.	—
3	—	748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded Several incident reports do not document the length of time a child was restrained.	—
2	—	748.915(a) - Document the caregiver?s completion of each training with cert or letter of completion in the appropriate FH or personnel record Three of four employee records reviewed were observed to be missing recent training certificates.	—
5	—	748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work. A staff member choked a child in care as a form of discipline.	—
4	—	748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Medical attention was sought for a child in care after a restraint was administered. Child reported of having stomach pains and was taken to the doctor the next day. Serious incident occurred on 2.11.2025, but was not called into RCCR.	—
4	—	748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work On the date of the incident the agency was not in ratio.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders Two staff members administered an additional prescription medication dosage to a child in care.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders Six children in care missed dosages of prescribed medications on multiple occasions for consecutive days.	—
4	—	748.2203(c)(2) - Medication Error-Document the medication error Medication errors were not documented for missed dosages of prescription medication for six children in care.	—
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply It was determined that a child in care was restrained for walking/not listening.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records While reviewing the child service plan it was discovered in the "Transitioning To Successful Adulthood," several statements indicated the child was a twelve-year-old, which was not true or accurate at the time this plan was completed. This section of the plan was also not current, as the child plan was a review and this section should've been completed at the time of the review as the child was fourteen years old at the time the plan was completed.	—
4	—	748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child Operational staff "chest bumped" child in care in a demeaning manner.	—
4	—	748.1205(a)(7) - Admission Documentation-Includes child's immunization record Children's records reviewed did not have an immunization record in the file.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Children in care reported that staff were asleep on shift, staff were observed unresponsive with their eyes closed shut.	—
1	—	748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting Notification of a Service Plan meeting occurring on 05/15/25 was not sent until 05/07/25.	—
1	—	748.1205(a)(6) - Admission Documentation-Includes medication the child is taking Admission Assessments did not include medications the children were taking.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A child in care was subjected to physical abuse by a staff member.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child During the course of this investigation, it was determined that a staff member was utilized inappropriate disciplinary practices by referring to a child using derogatory names.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The person list in the portal shows 8 active employees that are not documented on the employee list provided by the operation.	—
5	—	745.8641 - Requirements during probation Condition #1-Not Met Condition #2-Met Condition #3-Met Condition #4-Met Condition #5-Met Condition #6-Met	—
4	—	748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child Two of four children confirmed that staff member made improper comments.	—
3	—	748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling One of the four employee files reviewed was observed to be missing a high school diploma. The employee has been working at the operation since 01/24/22.	—
1	—	748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan During the review of files, services plans were not signed by all parties involved.	—
4	—	748.1699(a) - Nutrition-must offer a child a meal or snack, but may not force the child to eat Children in care reported that a staff member would force a child in care to eat food that he did not want to eat.	—
4	—	748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training. An employee was observed to be delinquent in completing the required annual Normalcy Training.	—
5	—	748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision It was reported that a staff member was asleep while providing supervision to children in care.	—
4	—	748.931(b)(1) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 2 hrs trauma informed care. It was determined that two trainings were over a year old.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A child in care suffered pain to the face as a result of a staff member horseplaying with the child.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Children in care reported that a staff member would make derogatory remarks in reference to the sexuality of a child in care.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model A medication log for a child in care was observed to have an inaccurate count of remaining medication.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation The allegations are related to a DFPS abuse/neglect investigation.	—
4	—	748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered One mediation log was observed to be missing the time the medication was administered to a child in care.	—
2	—	748.1205(a)(3) - Admission Documentation-Include names, addresses, phone numbers of bio or adoptive parents, unless parental rights terminated Admission Assessments did not include information for parents.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed 2 children in care were given one extra dosage of medication.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Operation staff engaged in a physical altercation with child in care and failed to call additional staff for assistance.	—
1	—	748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents A child's records reviewed did not have documentation that the service plan meeting letter was sent to all parties	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Video camera footage, captured by the facility, showed a staff using her forearm to push a child back into his room, forcing him to comply to directives for quiet, calm down time.	—
3	—	748.453(a)(4) - Unauthorized Absence - Annual summary log must include name of caregiver responsible for child at time absence discovered During the review of the investigation, it was found that the unauthorized absence did not contain the name of the caregiver responsible at the time of the absence.	—
1	—	748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents Children's records reviewed did not have documentation that the service plan meeting letter was sent to all parties.	—
4	—	748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223 A child admitted on 06/11/2024 did not receive an initial medical visit until 08/14/2024.	—
5	—	748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint A caregiver sought assistance from other children in care to restrain a child.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form In one of the four employee files reviewed, it was observed that an employee who began 01/24/22 did not have a notarized Affidavit for Applicants until 06/13/22.	—
4	—	748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children One caregiver was observed to be supervising 7 children in Llanos House.	Yes
3	—	748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented Log shows that smoke detectors were not tested in May 2023.	—
5	—	745.8641 - Requirements during probation Condition #1-Met Condition #2-Met Condition #3-Met Condition #4-Not Met Condition #5-Met Condition #6-Met	—
2	—	748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions Four of the four child records reviewed were observed to be missing immunization records.	—
5	—	748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication	—
4	—	748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child Three serious incidents for one child in care indicated suicide ideations and/or attempts. Neither of the three incidents were reported to Licensing.	—
2	—	748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan Children's records reviewed did not have current service plans completed in the file.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders One child in care was not administered prescribed medication for one month. A second child in care received two more milligrams of medication than what was prescribed.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language Four out of five children interviewed reported to hearing profane language being used to redirect the children. Three out of five staff interviewed acknowledged being aware of profane language being used to redirect the children.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Caregiver did not provide the 1:1 supervision required for a youth in care.	—
5	—	745.8641 - Requirements during probation Condition #1-Met Condition #2-Not met Condition #3-Not Met Condition #4-Met Condition #5-Met Condition #6-Met	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity Staff have fallen asleep when supervising children in care.	—
4	—	748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint Admission Assessments reviewed did not include any known contraindications to restraints.	—
4	—	748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used It was observed that an employee transported children in care with an expired driver's license.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders A child in care was administered an incorrect dosage of medication.	—
4	—	748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations While conducting the investigation of the facility it was found that the medication error was found on 1-18-23 and the child had still not received any medical attention as of 2-2-23 when the investigation was initiated.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report Operation does not have documented report of serious incident that occurred.	—
4	—	748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Staff performed a personal restraint on a child in care without there being an emergency situation.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model One of the child files reviewed was observed to have an inaccurate count of two medications documented on the medication log.	—
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 review of four employee records, it was noted that two of them lacked documentation verifying the completion of reference checks.	—
4	—	748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs During the course of the investigation, it was found that the medication error happened on 1-9-23 and it was not documented until 1-20-23.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Staff described physically picking up a child in care and placing him in his bedroom after an altercation with another child.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed	—
5	—	745.8641 - Requirements during probation Condition #1-Met Condition #2-Met Condition #3-Met Condition #4-Not Met Condition #5-Met Condition #6-Met	—
2	—	748.361(d) - Personnel records-The system for maintaining all records must be uniform throughout the operation Records were supplied in two formats: electronic and paper. However, the documents in both formats lacked uniformity, which created challenges in processing the information. Additionally, there were several missing documents in both the electronic and paper submissions, further complicating the review and analysis of the records.	—
5	—	748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision It was reported that a staff member was asleep while providing supervision to children in care.	—
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 Staff and residents interviewed stated a staff member called a resident a derogatory name.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model A medication log for a child in care was observed to have an inaccurate count of remaining medication.	—
4	—	748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children One caregiver was observed to be supervising 7 children in Llanos House.	Yes
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply It was determined that a child in care was restrained for walking/not listening.	—
4	—	748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223 A child admitted on 06/11/2024 did not receive an initial medical visit until 08/14/2024.	—

Severity 5 = most serious. Source: official state record.

Inspections (383)

383 inspection record(s) on file from TX-HHSC.

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