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Abundance of Joy Home Shelter

Child care center · 16335 BUNKER RIDGE RD, Houston, TX 77053-4758 · License 1711621

0Compliance score
Poor

Capacity 11. 5-13

Violation history (500)

Severity	Date	Standard / narrative	Corrected
3	—	748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child During the inspection; a post discussion was not completed after restraint conducted on a child in care.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old The operation did not provide a requested medication log after multiple requests.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair A window blind in one of the bedrooms was damaged.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication Medication logs reviewed, show no record of medication that was administered.	—
3	—	748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline Staff failed to report serious incidents involving children in their care to the hotline. Incidents involving physical abuse between children were not reported timely.	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity Staff are allowing children in care to fight without intervening.	—
3	—	748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention There was no documentation sent to inspector regarding EBI being performed on victim and documentation on EBI performed on other children in care who were interviewed	—
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 It was found that 2 out of 3 staff records that there was no high school diploma or GED in the file.	—
4	—	748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint Two out of four youth files reviewed did not include known contrindications to restraints for the youth.	—
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. The administrator did not have all required annual trainings.	—
3	—	748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Operation did not send any post EBI documentation regarding the victim or any child in care from the operation	—
1	—	748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents 2 children's service plans did not have the parent's signature.	—
5	—	748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing During the course of the investigation, a child in care reported not being able to breathe during a restraint involving staff sitting on them. The child reported breathing heavily once released. Three children interviewed also reported hearing the child say they could not breathe.	—
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area.	—
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 Two out of three child records reviewed did not contain a signed statement to acknowledge the child's rights.	—
4	—	748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate During an inspection at the operation, scissors were observed to be accessible in a drawer to youth in care recently after an incident involving scissors occurred with a youth at the operation.	—
2	—	748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children Recreational calendars provided for the past 90 days did not outline an indoor & outdoor recreational activity.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language There is information to confirm staff use profane language while caring for children.	—
4	—	748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI Reviewing staff training 5 out of 8 staff do not have up to date training for EBI	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair A window blind in one of the bedrooms was damaged.	—
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 A single caregiver was observed to be present with seven children in care.	—
2	—	748.2853(3) - EBI Documentation-Date and time the post discussion took place, if applicable During the inspection, two out of three restraint reports had missing post discussion documentation.	—
3	—	748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission annual summary log was not given to inspector regarding AWOL as requested	—
3	—	748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements Staff Anthony Baldwin left the operation and went to work for another place not related and came back 2 years later. He had no updated TB test in file since being unemployed by a regulated operation within the previous 12 months.	—
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean Two of two bathrooms utilized by children in care did not contain: paper towel or any hand drying agent. One of two bathrooms did not contain toilet paper, One of two bathrooms had a broken vanity exposing piping. One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area. There was bag of meat in the freezer in a ripped bag exposing the meat. There was a clump of hair in the freezer.	—
3	—	748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position One out of seven employee files reviewed did not contain an updated professional licensure as required for their job position nor any record of training completed. Another employee file did not contain a job description.	—
3	—	748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent. Two out of two restraints reviewed did not include a notification to the parent.	—
5	—	748.4045 - Safety restraints-only one person may use each child passenger safety seat system or safety belt Two children used one seat belt while being transported for an outing.	—
2	—	748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.	—
4	—	748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child. Staff failed to report serious incidents involving children in care to the parents. Children have been involved in serious incidents requiring medical evaluations after and parents have not been informed within required time frames.	—
5	—	748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint Due to 5 out of 8 staff EBI records no being current. 5 staff are not qualified to perform EBI.	—
3	—	748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity A caregiver took five children in care, ages 9-13, to see a horror movie rated PG-13. Several of these children have history of self-harm and have experienced significant trauma. One child?s Conservatorship worker stated that due to her diagnosis, her mindset is much younger than her age.	—
3	—	748.1531(b)(5) - Medical Care-Written record of each medical examination includes any documentation provided by health-care professional who performed exam The operation documents on their incident reports that children are being evaluated by their concierge doctor however there is not always documentation to go along with this and when a document is provided it does not have any official signatures or letterhead and it is unknown who is filling out the document .	—
5	—	748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint During the course of the investigation, it was reported that staff sat on a child?s lungs and belly during a restraint. Three children interviewed corroborated the child's statement.	—
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection The operation's last fire inspection was 8/17/2023.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication One out of three medication records reviewed had signatures documented/signed prior to administering any medication to children in care.	—
4	—	748.930(a)(1) - Caregivers at operations with less than 25 children or 30% of their population receiving treatment services must have 20hrs annual training Several staff members failed to complete required training prior to being counted in ratio.	—
3	—	745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving The operation has an active background check for staff that no longer works for the operation.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication Medication logs reviewed did not include the reason medication was prescribed.	—
1	—	748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.	—
4	—	748.930(a)(2) - Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training One out of three employee files reviewed only contained 34 annual training hours instead of the required 50 hours.	—
5	—	748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator The operation has not had an administrator in 90 days.	—
3	—	748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill There is no record of practice severe weather drills.	—
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. 1 of 2 direct staff did not have psychotropic medication training.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report A serious incident that was reported to the statewide intake hotline by the operation did not have a coinciding report documented at the operation.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model One out of three medication records reviewed indicate that the medication count was inaccurately logged.	—
4	—	748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization. A suicide risk screening was not conducted with a child post returning from the psych hospital.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report No serious incident report was given to inspector regarding AWOL of victim that was called in to licensing	—
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 staff member supervised 6 children in a van on 03/20/2022 when a physical altercation occurred.	—
3	—	745.651(2)(A) - Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list The last validation of the employee list in the provider portal was four months ago.	—
2	—	748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level It was found in 2 out of 3 children files reviewed that no child orientation was provided upon admission.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Prudent judgement was not demonstrated when children in care were asked to write a reference letter for a caregiver caring for the children.	—
3	—	748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction The purpose of this standard is to ensure child care regulation is able to assess records and documentation for accuracy and compliance.	Yes
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 has not entered EBI data in their provider portal for Quarter 4 of 2023.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair A window blind in one of the bedrooms was damaged.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container During the inspection; medication was observed accessible to the children in care and child in care pick up a pill off the floor.	Yes
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. Staff Anthony Baldwin No verification in file that employment history or reference checks were completed	—
5	—	748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator The operation has not had an administrator in 60 days.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair A window blind in one of the bedrooms was damaged.	—
3	—	748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes Four out of four fire/evacuation drills reviewed were not completed within the required three minutes. One out of the four drills reviewed did not indicate the smoke alarm was set off.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The operation provided medication logs for the month of November that do not contain consistent information.	—
3	—	748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment. Anthony Baldwin DOH: 6-17-24 748.505(5)-No Affidavit Form 2912 in file	—
2	—	748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements One out of three child files reviewed did not contain a copy of the initial service plan in the file. Two out of three children's files did not contain the most recently updated service plan in the file.	—
3	—	748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention Staff failed to complete EBI documentation for serious incidents involving children in their care.	—
4	—	748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return No debriefing documentation was given to inspector regarding AWOL of victim	—
5	—	748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator The operation has not had an administrator in 60 days.	—
4	—	748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI Reviewing staff training 5 out of 8 staff do not have up to date training for EBI	—
2	—	748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.	—
2	—	748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children Recreational calendars provided for the past 90 days did not outline an indoor & outdoor recreational activity.	—
1	—	748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.	—
3	—	748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child During the inspection; a post discussion was not completed after restraint conducted on a child 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. The administrator did not have all required annual trainings.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report No serious incident report was given to inspector regarding AWOL of victim that was called in to licensing	—
3	—	745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving The operation has an active background check for staff that no longer works for the operation.	—
3	—	748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements Staff Anthony Baldwin left the operation and went to work for another place not related and came back 2 years later. He had no updated TB test in file since being unemployed by a regulated operation within the previous 12 months.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report A serious incident that was reported to the statewide intake hotline by the operation did not have a coinciding report documented at the operation.	—
3	—	748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention There was no documentation sent to inspector regarding EBI being performed on victim and documentation on EBI performed on other children in care who were interviewed	—
1	—	748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents 2 children's service plans did not have the parent's signature.	—
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 staff member supervised 6 children in a van on 03/20/2022 when a physical altercation occurred.	—
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 It was found that 2 out of 3 staff records that there was no high school diploma or GED in the file.	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity Staff are allowing children in care to fight without intervening.	—
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 has not entered EBI data in their provider portal for Quarter 4 of 2023.	—
5	—	748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint During the course of the investigation, it was reported that staff sat on a child?s lungs and belly during a restraint. Three children interviewed corroborated the child's statement.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair A window blind in one of the bedrooms was damaged.	—
4	—	748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child. Staff failed to report serious incidents involving children in care to the parents. Children have been involved in serious incidents requiring medical evaluations after and parents have not been informed within required time frames.	—
4	—	748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint Two out of four youth files reviewed did not include known contrindications to restraints for the youth.	—
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. 1 of 2 direct staff did not have psychotropic medication training.	—
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 Two out of three child records reviewed did not contain a signed statement to acknowledge the child's rights.	—
3	—	748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Operation did not send any post EBI documentation regarding the victim or any child in care from the operation	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication One out of three medication records reviewed had signatures documented/signed prior to administering any medication to children in care.	—
3	—	748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission annual summary log was not given to inspector regarding AWOL as requested	—
3	—	748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity A caregiver took five children in care, ages 9-13, to see a horror movie rated PG-13. Several of these children have history of self-harm and have experienced significant trauma. One child?s Conservatorship worker stated that due to her diagnosis, her mindset is much younger than her age.	—
3	—	748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill There is no record of practice severe weather drills.	—
3	—	748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction The purpose of this standard is to ensure child care regulation is able to assess records and documentation for accuracy and compliance.	Yes
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model One out of three medication records reviewed indicate that the medication count was inaccurately logged.	—
4	—	748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return No debriefing documentation was given to inspector regarding AWOL of victim	—
4	—	748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate During an inspection at the operation, scissors were observed to be accessible in a drawer to youth in care recently after an incident involving scissors occurred with a youth at the operation.	—
3	—	748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent. Two out of two restraints reviewed did not include a notification to the parent.	—
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 A single caregiver was observed to be present with seven children in care.	—
5	—	748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing During the course of the investigation, a child in care reported not being able to breathe during a restraint involving staff sitting on them. The child reported breathing heavily once released. Three children interviewed also reported hearing the child say they could not breathe.	—

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

Inspections (248)

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

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