Texas › Conroe › Creighton Oaks Residential Treatment Center

Creighton Oaks Residential Treatment Center

Child care center · 11313 LONG DRIVE, Conroe, TX 77302 · License 1721455

0Compliance score
Poor

Capacity 71. 8-17

Violation history (500)

Severity	Date	Standard / narrative	Corrected
3	—	748.363(5) - Personnel records-Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position. While reviewing files it was found that multiple items were missing.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair Photos were reviewed of exposed nails and screws on a bedframe, broke outlet cover and holes in the walls.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation It was found during the investigation that vehicle keys were left unsecured which resulted in children in care stealing the operation van.	—
4	—	748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette The agency's policy does not address tobacco and e-cigarette.	—
3	—	748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below The deep freezer in the kitchen does not have a thermometer.	—
4	—	748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required While reviewing files it was found the supervision section did not include information about day to day supervision requirements in the home or supervision outside the home.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair It was observed that a broken dresser in Bedroom 5 of the green house has not been removed.	—
3	—	748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center. While reviewing the screenings it was found they were not being completed within 30 days of the last screening.	Yes
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair During the walkthrough each of the bedrooms were observed to be unclean, with beds unmade, clothing and shoes throw around the room.	—
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 drove children in care around with confiscated drugs in the glovebox.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair Bathroom sink for bedrooms two and three in Peach House are slow draining. Bathroom sink for bedroom six in the Grey House is also slow draining.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation The allegation is related to a DFPS abuse/neglect investigation.	—
4	—	748.4653(a)(3) - Pre-Service Training- All caregivers must have 5 hrs of training on complex trauma of trafficking victims, 2 hrs pre-service and rest within 90 days Policy does not indicate complex trauma training for caregivers of human trafficking victims.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. 2 of 3 employee files did not have documented reference checks.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A staff member admitted to sleeping on shift.	—
3	—	748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions During the investigation, required documentation couldn't be provided for a serious incident.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A child in care had a prohibited item which wasn't locked back up and resulted in another getting injured.	—
3	—	748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement While reviewing the files, children did not have safety plans in place at the time of admission.	—
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 Several children were caught intentionally inhaling axe body spray. This incident was never reported by the agency to Licensing.	—
4	—	748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards A portion of two door frames were observed to be broken. One of the doors was observed to have broken door handle.	—
1	—	748.1217(b)(1) - Admission Assessment-At admission, must include child's legal status The admissions assessment does not include the child's legal status.	—
4	—	748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions There were several food items observed to be expired and without expiration dates in the library refrigerator/freezer.	—
4	—	748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director The facility does not have a treatment director.	—
3	—	748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Documentation provided stated the post discussion was held with the child and a staff that was not involved in the restraint.	—
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 made inappropriate comments regarding a child's physical ability and inappropriate comments regarding sexuality.	—
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 did not receive two doses of their morning medication.	—
3	—	748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered Documentation provided only listed a two-person restraint as being used, but no specifics.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 2 of 2 files did not have pre-employment affidavits.	—
5	—	748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child While reviewing video of the incident a child was inappropriately restrained.	—
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 After speaking with multiple caregivers and residence, I became aware that a caregiver was not present during the incident and the operation was out of ratio with 15 residents and 2 staff members.	—
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. 2 of 2 files did not have employment verification completed.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records 1 service plan referenced the child by a name other than their own and 3 entries on the unauthorized absence log had information pertaining to a different child than the one being discussed.	—
1	—	748.1117(3) - Documentation of searches-Document the reason for the search in the child's record While reviewing search records for children's rooms/possessions it was observed that required information was missing from the reports.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. During the walkthrough of the operation various cleaning chemicals were observed unsecured in the kitchen drawers and under the kitchen sink.	—
3	—	748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator During the walkthrough of the operation food was observed in refrigerator unsealed in two different units. Staff was asked to throw away several pounds of bad cheese during the walk through.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being During the course of the investigation, it was revealed that multiple children in care stole equipment with the intent to sell, indicating insufficient supervision and increased risk to their safety.	—
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 admitted to hitting a child in care.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. One incident report on 10/15/23 involving a teenager in care, was called in past the 6-hour required timeframe for reporting to the A/N hotline for an unauthorized absence and Law Enforcement was not contacted. For another unauthorized absence incident involving two other children in care, on 10/14/23, law enforcement was also not contacted.	—
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection The CLASS system shows the most recent fire inspection was 04-09-2024. The operation had records of requests to have the inspection completed by 04-09-2025. The FIre marshall inspected the operation on 04-16-2025 and the operation didn't pass. The operation had a change in management and got a passing inspection on 10-06-2025.	Yes
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply An incident report, dated 9/11/23, described a 12-year-old being restrained for attempting to runaway into the woods.	—
1	—	748.1205(a)(5) - Admission Documentation-Includes date of admission The date of admission is not listed on the admission documents.	—
3	—	748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained While reviewing files it was observed that the admission assessments did not contain all required information.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A child in care obtained bullets from the operations van.	—
3	—	748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below The right refrigerator is at 50 degrees Fahrenheit	—
3	—	748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill The operation had no documentation of any emergency drills in over six months.	—
2	—	748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review Fire extinguisher on the second floor of the green house expired in August of 2024.	Yes
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean During the walk through of the operation, multiple bathrooms were found to have trash on the floors, urine on and around the toilets and soap on the floors.	—
3	—	748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction There was no active record available for the operations administrator.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A staff was observed sleeping by a Department staff and operation staff.	—
4	—	748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child A child made an outcry of physical abuse to multiple staff by a staff member that was not reported.	—
3	—	748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being All staff stated there were all in different location when the incident occured.	—
5	—	748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain A child in care did not receive immediate medical attention after receiving burns to their arms.	—
5	—	748.3315 - Water-A thermostat must control the temperature of hot water accessible to children, so the temperature is no higher than 120 degrees Fahrenheit The bathroom sink and shower water in room 2 of the Green house was observed to with no hot water.	—
5	—	748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others Three children's service plans reviewed were missing some high risk behaviors although it is noted in other sections of the plan that the children have history of unsafe behaviors such as verbal and/or physical aggression, substance use, delinquency, threats of self-harm and harm to peers, and/or run away. There was also no documentation of known triggers for the children on the plan.	—
3	—	748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older. The operation did not report a child in care unauthorized absence to Licensing or their parent within the allotted timeframe per minimum standards.	—
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 During the investigation it was found the office door, which is the second lock for medications, was left unlocked and children in care were able to access the office.	—
5	—	745.4151(a) - Operation must adopt the DFPS drug testing policy or have its own that meets or exceeds criteria for model policy Drug polices do not address all information provided in the model drug testing policy.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders Two of seven children's medication file reviewed revealed a medication being administered not according to the label/order.	Yes
4	—	748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist. While reviewing 4 staff files it was discovered staff were not receiving instructor-led pre-service psychotropic medication training by a health-care professional.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language A caregiver admitted to using inappropriate/profane language about a child in care in their presence.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. Cleaning products were found under the kitchen sink in Peach house.	Yes
4	—	748.3301(h) - Physical Site-The building must be free of rodents and insects The green house was observed to have dead wasps in the light fixture.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A staff member admitted to sleeping on shift.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language A caregiver admitted to using inappropriate/profane language about a child in care in their presence.	—
2	—	748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review Fire extinguisher on the second floor of the green house expired in August of 2024.	Yes
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. Cleaning products were found under the kitchen sink in Peach house.	Yes
4	—	748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette The agency's policy does not address tobacco and e-cigarette.	—
3	—	748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill The operation had no documentation of any emergency drills in over six months.	—
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 did not receive two doses of their morning medication.	—
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 drove children in care around with confiscated drugs in the glovebox.	—
5	—	745.4151(a) - Operation must adopt the DFPS drug testing policy or have its own that meets or exceeds criteria for model policy Drug polices do not address all information provided in the model drug testing policy.	—
4	—	748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions There were several food items observed to be expired and without expiration dates in the library refrigerator/freezer.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair During the walkthrough each of the bedrooms were observed to be unclean, with beds unmade, clothing and shoes throw around the room.	—
5	—	748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child While reviewing video of the incident a child was inappropriately restrained.	—
3	—	748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions During the investigation, required documentation couldn't be provided for a serious incident.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A staff was observed sleeping by a Department staff and operation staff.	—
3	—	748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below The deep freezer in the kitchen does not have a thermometer.	—
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. 2 of 2 files did not have employment verification completed.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair Bathroom sink for bedrooms two and three in Peach House are slow draining. Bathroom sink for bedroom six in the Grey House is also slow draining.	—
3	—	748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being All staff stated there were all in different location when the incident occured.	—
3	—	748.363(5) - Personnel records-Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position. While reviewing files it was found that multiple items were missing.	—
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 made inappropriate comments regarding a child's physical ability and inappropriate comments regarding sexuality.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A child in care obtained bullets from the operations van.	—
5	—	748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others Three children's service plans reviewed were missing some high risk behaviors although it is noted in other sections of the plan that the children have history of unsafe behaviors such as verbal and/or physical aggression, substance use, delinquency, threats of self-harm and harm to peers, and/or run away. There was also no documentation of known triggers for the children on the plan.	—
4	—	748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director The facility does not have a treatment director.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A child in care had a prohibited item which wasn't locked back up and resulted in another getting injured.	—
5	—	748.3315 - Water-A thermostat must control the temperature of hot water accessible to children, so the temperature is no higher than 120 degrees Fahrenheit The bathroom sink and shower water in room 2 of the Green house was observed to with no hot water.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. One incident report on 10/15/23 involving a teenager in care, was called in past the 6-hour required timeframe for reporting to the A/N hotline for an unauthorized absence and Law Enforcement was not contacted. For another unauthorized absence incident involving two other children in care, on 10/14/23, law enforcement was also not contacted.	—
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 Several children were caught intentionally inhaling axe body spray. This incident was never reported by the agency to Licensing.	—
4	—	748.4653(a)(3) - Pre-Service Training- All caregivers must have 5 hrs of training on complex trauma of trafficking victims, 2 hrs pre-service and rest within 90 days Policy does not indicate complex trauma training for caregivers of human trafficking victims.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.	—
3	—	748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered Documentation provided only listed a two-person restraint as being used, but no specifics.	—
4	—	748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards A portion of two door frames were observed to be broken. One of the doors was observed to have broken door handle.	—
4	—	748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist. While reviewing 4 staff files it was discovered staff were not receiving instructor-led pre-service psychotropic medication training by a health-care professional.	—
1	—	748.1205(a)(5) - Admission Documentation-Includes date of admission The date of admission is not listed on the admission documents.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation It was found during the investigation that vehicle keys were left unsecured which resulted in children in care stealing the operation van.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 2 of 2 files did not have pre-employment affidavits.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair Photos were reviewed of exposed nails and screws on a bedframe, broke outlet cover and holes in the walls.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. During the walkthrough of the operation various cleaning chemicals were observed unsecured in the kitchen drawers and under the kitchen sink.	—

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

Inspections (280)

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

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