Capacity 10. 9-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 5 | — |
748.4231(b)(3) - Admission assessment for emergency and respite care services-obtain as soon as possible information on the medications the child is taking
One emergency placement child's admission assessment does not list the child's medications. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
The single evacuation plan in the operation was observed without a designated shelter inside location. |
Yes |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
There were 3 medication counts that were different than what was documented. |
— |
| 4 | — |
748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.
One child's admission assessment reviewed did not include the child's trauma history. |
— |
| 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
Background checks have never been validated. |
— |
| 1 | — |
748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
The childs service plan reviewed did not include the child's signature or a explaination of refusal. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the inspection, a staff was seen and heard sleeping while supervising a child in care for at least 10 minutes. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The childs file reviewed did not include a complete preliminary plan for discharge. |
— |
| 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 walkthrough of the facility, one of the couch in the living room area was observed not to be in good repair condition. The chair is very uncomfortable and you can feel the spring when you seat on it. One cabinet was also observed to be damaged in the restroom. |
— |
| 3 | — |
748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered
The restraint report does not include the specific EBI administered or the specific restraint technique used. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
Stair well bannister was missing piece. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
The advance 2 weeks notice to the DFPS staff regarding initial service planning meeting was missing in the childs file. |
— |
| 5 | — |
HRC42.04412(a) - Interference with an investigation
There is currently an open Abuse Neglect investigation involving a staff member. The operation was asked to remove the staff member during the course of the investigation. The operation has refused the safety plan that appropriately addressed the risk to children. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
Staff file reviewd did not have date of employement. |
— |
| 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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The staff list provided during the inspection was not consistent with the CLASS background check data. The staff list was last validated on the day of the inspection. |
— |
| 1 | — |
748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom
Multiple children are utilizing the downstairs bathroom located inside of the recreational area to shower, when their bedroom is upstairs. |
— |
| 5 | — |
745.8641 - Requirements during probation
Per condition 5, the operation LCCA should have conducted a meeting with all staff employed within 15 days of the start the probation period. All staff that attended the meeting should have signed an attendance log. |
— |
| 3 | — |
748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies
One staff members file did not contain a statement signed and dated that they read a copy of the operational policies. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
Based on information gathered during a review of the operation's documents, it was found two out two children's Discharge Summaries did not contain the reason medication was prescribed. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
A child's 30, 60 and 90 day placement extension documentation were observed to be pre-dated and completed at initial placement for placement extensions. |
— |
| 1 | — |
748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days
4 of 5 children receiving emergency care services have been in care longer than 15 days without an extension. |
— |
| 1 | — |
748.4209(a) - Placement Extension-Child's service planning team must document the reason for the placement extension in the child's record
Three placement extensions for a child in care was observed without an applicable reason to keep the child in the emergency placement. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During today's inspection, bedroom three was observed to have still have the window screens to still be damaged along with an additional screen. |
— |
| 5 | — |
745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
One employee file did not have an up to date drug test. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
PLSP did not sign and date the 1 assessment that was completed. |
Yes |
| 3 | — |
748.363(13) - Personnel records-Include record of training and training hours.
Suicide prevention training does not contain how many hours the training was conducted. |
— |
| 3 | — |
748.1221(c)(1) - Admission Assessment-Document why a particular piece of information is unavailable
In 2 out of the 4 files reviewed the admission assessment did not have the all the required components such as the parents and siblings name, address and contact information. There was also no documentation in the file as required per minimum standards. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
One child's file reviewed did not contain a preliminary service plan. |
— |
| 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 bathroom sink upstairs was not equipped with soap or anything for the children to dry thier hands. |
Yes |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
Food were observed stored on the ground inside the storage in the kitchen area during the walkthrough. |
— |
| 3 | — |
748.831(a)(3) - Orientation-Orientation must include the needs and characteristics of children that the operation serves
staff orientation checklist is missing the topic of the types of children they serve. |
— |
| 4 | — |
748.1217(b)(4) - Admission Assessment-At admission, must include any history of physical, sexual, or emotional abuse or neglect
One child's admission assessment did not include their history of physical, sexual, or emotional abuse or neglect. |
— |
| 4 | — |
748.1205(a)(7) - Admission Documentation-Includes child's immunization record
One child's record reviewed did not contain their immunization record or proof the immunization record was requested. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
Admin did not document serious incident reports after the children were bitten, until after being inquired about an incident report for the victim child by their caseworker. All children were later instructed to put in writing what occurred and that they declined medical care. |
Yes |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly
During the walk-through, poisonous chemicals were observed to be accessible to children in care. |
Yes |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
One discharged child's file did not list the circumstance of the discharge. The discharge summary also did not have the date or time the child was notified. |
— |
| 4 | — |
748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI
In 1 out of 2 staff files the employee needed the refresher EBI course by 3/7/22 and has not completed it. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
Operation did not have written plan for protecting children in care from TB as stated in their policies/procedures. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Two out of three child files reviewed contained conflicting information on multiple documents. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of a childs file, multiple dates of birth were noticed. The date of birth in the intake form, the binder cover and placement summary says 9 years while the discipline notification form for the child says child is 10 years. |
— |
| 3 | — |
748.2101(8) - Medication Storage & Destruction-remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access
Medications for two discharged residents was observed stored at the operation. |
— |
| 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 contractor worker witnessed the staff saying belittling remarks towards children in care. |
— |
| 1 | — |
748.1337(b)(1)(K) - Initial Service Plan-Include names and roles of persons who participated in service plan development
One child initial service plan was missing the names of the participants. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
One child's medication log did not contain the prescribing healthcare professionals name, the reason the medication was prescribed, the medication's name, the dosage and the strength. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
During the inspection, there were no documented Unauthorized Absence Logs for review. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
3 out of 4 children interviewed stated a staff member does not come upstairs to check on them. A staff member did not immediately intervene with a child who was self-harming. Additional supervision was not provided to a child who was making suicidal ideations and self-harming. |
— |
| 3 | — |
748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available
Per the Administrator, Health/Sanitation Inspections are not available in the area that the operation is located, there is no documentation of that determination for review. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Licensing representative requested for staff file for review at about 10:am but file was not made availabe to licensing staff until after 1 hour of the request becasue the administrator was not at the facility. |
— |
| 5 | — |
745.8411(b)(3) - Responsibilities - Provides access to all records
The Administrator refused to allow DFPS access to video of staff supervision, to document in their investigation. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or
In 4 out of the 4 files reviewed there was no documentation on the exterior of the record to indicate if the child had any chronic conditions. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
One pack of mashed potatoes was observed open inside the fridge during the walkthrough. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
One employee record did not contain true and accurate information of their date of birth. A child's admission assessment lacks pertinent details. The staff list did not accurately reflect active employees. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The operation had the forms but had not filled them out for their awol's. |
— |
| 3 | — |
748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
Two children in care were charged with a crime by law enforcement on 05/06/2023, the incident was not reported to Licensing until 05/08/2023. |
— |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
Four psychotropic medications were observed stored single locked. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Five out of five kids interviewed disclosed staff yells at them, and three out of five kids interviewed disclosed hearing staff call a child in care mother a bad name. |
— |
| 5 | — |
745.8311(b) - Waiver/Variance - Comply w/ each condition while in effect
The operation did not comply with the conditions of notification of discharge to licensing on multiple variances. |
— |
| 2 | — |
748.361(d) - Personnel records-The system for maintaining all records must be uniform throughout the operation
Required documents for files were not all kept in one consistent place for review. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children interviewed stated the staff do not check on them and are always on their phone. |
— |
| 3 | — |
748.535(3)(C) - Child-care administrator responsibilities-Having system in place to ensure an employee is available for emergencies
The operation did not have available staff to pick a child up from school when needed. |
— |
| 4 | — |
748.151(4) - Operational responsibilities - Allow Licensing to inspect the operation during its hours of operation
On June 3, 2026, an HM inspection was attempted at the operation by RCC. There was no staff present at the operation. |
— |
| 3 | — |
748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care
One child's admission assessment did not include a description of circumstances that led to the child's referral for substitute care. |
Yes |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
1 of 2 children interviewed stated they have heard staff yell and use profane language towards children in care. |
— |
| 2 | — |
748.1439(b)(2) - Discharge Documentation-Send copy of child's background info, including progress notes for past 60 days, to next placement/caregiver within 15 days
Case worker reported the agency did not provide the child's progress notes after the child was discharge. |
— |
| 1 | — |
748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves
The provided Menu did not list all daily meals and snacks provided by the operation. Nor did it list food substitutions, and there were no menus for review for the last 90 days. |
— |
| 2 | — |
748.1217(b)(15) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child
One child's admission assessment did not include a determination of whether the operation can meet the immediate needs of a child. |
Yes |
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
The provided First Aid Kit did not have a thermometer or waterproof disposable gloves. |
— |
| 4 | — |
748.3233(b)(1) - Evacuation-Emergency evacuation & relocation diagram must include a floor plan of the operation
The posted Emergency Evacuation diagram does not include the 2nd floor to the operation, nor does it include the designated location inside operation to take shelter from threatening weather. |
— |
| 5 | — |
HRC42.04412(a) - Interference with an investigation
Staff member lied to RCCI investigator when asked if they went by a different name. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
Three out of three child files reviewed did not contain an immunization record. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Operation is not providing documentations in a timely manner. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or
One child's file did not indicate whether the child had any known allergies. |
— |
| 5 | — |
745.4151(c)(6)(A) - Discipline-An applicant or employee's consent to submit to drug testing is required as a condition of employment
One staff file reviewed did not have the signed consent form for a drug test. |
— |
| 5 | — |
748.4203 - Admission-Each child receiving emergency care services must receive a health screening or EPSDT examination within 72 hours after admission
A child received their 72-Hour Health Screening late. |
— |
| 3 | — |
748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care
Three out of three child's admission assessment does not include a description of the circumstances that led to the child?s referral for substitute care. Three out of three admission assessment did not state the services the operations plans to provide the child. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member reported contacting the LCCA for onsite help and was denied. |
— |
| 4 | — |
748.151(4) - Operational responsibilities - Allow Licensing to inspect the operation during its hours of operation
Today HM Inspector showed up to complete the inspection for Heightened Monitoring and no staff or administrator was available to complete the required inspection. Inspector tried calling and texting the administrator to come to the operation and no response. |
— |
| 4 | — |
748.3301(h) - Physical Site-The building must be free of rodents and insects
Several dead flies were observed in the common area down stairs beside the damged couch. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
The operation was cited for this standard during the last HM inspection on 4-2-25. During the follow up by inspection at the facility today, it was observed that the damaged couch and cabinet in the restroom has not been repaired or removed to ensure the safety of the children. |
— |
| 4 | — |
748.1271(3) - Emergency Admission Documentation-Include any allergies (food, medication, sting, skin allergies)
In 1 out of 4 files reviewed there is no indication if the child has any allergies, there is a space on the admission assessment form for that to be documented however it is blank. |
— |
| 4 | — |
748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
The fire extinguisher located in the kitchen, although still current on inspection, indicates empty (lost pressure) and needs to be refilled or replaced. |
— |
| 1 | — |
748.4209(a) - Placement Extension-Child's service planning team must document the reason for the placement extension in the child's record
In one child's file reviewed, the reason for their placement extension was not documented. |
— |
| 3 | — |
748.2951(d) - Evaluation-Results of each overall annual evaluation made available to Licensing for review.
The operation did not have an annual evaluation for review. |
— |
| 1 | — |
748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided
A written Recreation Plan was not available for review during the inspection. |
— |
| 1 | — |
748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days
One child receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted a placement extension. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
The backyard of the operation was observed to have several nails exposed in two different areas. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
At the time of the investigation inspection, 1 out of 2 files reviewed was missing child's current service plan. |
— |
| 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.
A child exhibited warning signs of suicide, and no documentation of a risk assessment was conducted. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
No documentation was completed for 2 out of 3 child files reviewed. |
— |
| 4 | — |
748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs
Based on information gathered during the investigation, it was determined a staff member did not provide appropriate supervision resulting in an adolescent running away. |
— |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
One staff file reviewed did not have the required 4 hours of preservice training. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
One staff member who was supervising a child in care was observed to be sleeping. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met/Not Met -Quarterly Individual Meetings: (Met) -Every 2-month observations of direct care staff: (Not Met) Two staff have no documentation of observations (to occur every 2 months) conducted by the LCCA. One staff has not had a documented observation conducted since Sept 2023 (required to occur every 2 months). |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During todays inspection, one children bedroom window screen was observed to be damaged which may result to insects gaining access into the children room. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The freezer in the garage contained food items. There was no thermometer located inside the freezer to obtain a temperature reading. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The operation is refusing to follow a safety plan requested by CCI stating they do not have any back-up caregivers. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on April 9, 2026 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
— |
| 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
Upon conducting background checks, a former employee's employment status read active. Work duration was August 2024 to September 8, 2024. Her background still viewed as active on 10/7/24. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of this investigation, it was noted that staff used the date 1-26-25 as the date of incident involving the victim child in an incident report while child was admitted to the facility on 1-28-25 according to the child's 72 hours service plan. Child was not at the facility on 1-26-25. |
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360 inspection record(s) on file from TX-HHSC.