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Wholeness Haven Inc.

Child care center · , TX · License 1746008

0Compliance score
Poor

Capacity 20. 7-17

Violation history (392)

SeverityDateStandard / narrativeCorrected
4— 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
There were damage found with the fencing, security of the perimeter and damaged outside.		 —
5— 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting
Staff was observed hitting and punching a child on video.		 —
4— 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
Review of kids in care medication administration records revealed medications were not administered as prescribed.		 —
3— 748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The operation failed to timely input quarterly date for EBI's for the 4th quarter of 2025 and the first quarter of 2026.		 —
4— 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
Child in care was given a different dose of medication as prescribed.		 —
5— 748.3601(9) - Swimming Pool-swimming area rules & emergency procedures must be posted at the swimming area & explained to the children
There were no rules or emergency procedures posted in the pool area.		 —
4— 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Caregivers failed to properly supervise a child in care who was exhibiting high risk behaviors.		 —
1— 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate. At minimum must give copy to child 14 years and older
A child did not receive a copy of their initial 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 in care displayed warning signs to a staff member and a screening being done was not recommended.		 —
4— 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff did not exercise prudent judgement when they allowed a child in care to operate a motor vehicle without a valid driver's license.		 —
4— 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours
Based on interviews and documentation, an employee was found to be sleeping while taking care of children.		 —
4— 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
Seven medication records reviewed did not have an accurate pill count documented.		 —
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 was involved in physical altercation which resulted in two black eyes and no medical care was sought.		 —
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
A staff member did not complete the required refresher EBI training.		 —
3— 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
Multiple active employee records have an incomplete/unnotarized Licensing Affidavit for Applicants for Employment form.		 —
2— 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the investigation it was found that a child's service plan was not completed timely.		 —
3— 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
The author of an incident report, failed to document her involvement during a restraint of a child in care.		 —
3— 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
Multiple active employee files reviewed have no record of a Pre-Employment Affidavit for Applicants for Employment form.		 —
2— 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
A youth's initial service plan wasn't developed timely after their admission.		 —
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's right to be free of neglectful supervision was not upheld when staff did not implement policy and demonstrated disregard by leaving children in care unattended in the operation's van with the keys in addition to allowing the child to operate the vehicle. These actions demonstrated negligence. This standard was found deficient as part of a DFPS Investigation.		 —
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
On 8/19/2025 a youth in care was transported to the hospital for medical evaluation for a hand injury. After clearance the youth was admitted to a psychiatric hospital for suicidal ideations & unsafe behaviors. This incident was not reported to Licensing.		 —
5— 748.3603(f) - Swimming-Fence gates to outdoor pool must have self-closing/self-latching hardware 60 inches from the ground and must be locked when pool not in use
The gate surrounding the pool did not have self-latching hardware.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
2 staff files and 1 child file were reviewed. Each file contained paperwork that was incomplete.		 —
4— 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units
The smoke detectors were sounding off on both levels . The detectors needed to have new batteries.		 Yes
4— 748.3233(b)(4)(E) - Evacuation-Emergency evacuation & relocation diagram includes 2 exit routes that are not doors or windows that require key to open from inside
The emergency diagram showed three downstairs emergency exits that were locked from the inside, required a key to open, and two of the three exits were a pathway through the kitchen.		 —
2— 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times
The permit was not posted anywhere at the operation.		 Yes
4— 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use
During the following application the agency didn't list the types of restraints that will be administered. A complete description of the TBRI information is needed.		 —
5— 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
Staff was observed on video attempting to wrap their arms around a child's neck. Staff was also observed pushing the child to the floor.		 —
3— 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Six medication records for children were observed without documentation of the prescribing physician.		 —
3— 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Staff did not follow the operation's policy when they left children unattended in the van with the keys.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
In review of a child service plan, the last vision screening was completed on 11/4/2024, however her last screening was completed on 11/5/2025.		 Yes
3— 748.311 - Serious Incident Documentation-Documented in written report
Serious incident report was missing documentation, the incident of how a child in care received two black eyes was not documented.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The records/documentation were not consistent, accurate, or completely filled out on the paperwork from the operation during the inspection.		 —
5— 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint
Child in care was face down during restraint.		 —
4— 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
Medication that was administered to a youth in care on 5/5/2025 at 7:00A was not recorded on the medication log until 5/6/2025 at 1:00P. Operation staff admitted during an inspection they failed to record administration of medication timely.		 Yes
4— 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff was observed inappropriately disciplining a child and attempting to place the child in a chokehold, this also included pushing and shoving the child to the ground.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
An incident report was found to have inaccurate information. The date of the incident was incorrect. In addition, a caregiver named in the report was not present on the day of the incident.		 —
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 documentation of any practiced severe weather drills in the past 6 months.		 —
3— 748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement
During the investigation it was found that a child's high risk behavior was identified at admission and a safety plan was not implemented to address that behavior.		 —
5— 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff should manage the children effectively and try and prevent situations. Staff are allowing children that were involved in a physical altercation share a room.		 —
1— 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event
Documentation to be reviewed were not in the youth's files timely although they were able to be provided.		 —
5— 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff allowed a child to drive without staff supervision and left the van keys accessible, which later led to the van being stolen and crashed.		 —
3— 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Licensing did not have access to all active records during a monitoring inspection.		 —
2— 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children
The recreational calendar reviewed during inspection does not include both indoor and outdoor daily activities.		 —
4— 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings
There were no emergency evacuation diagrams posted in the home.		 —
5— 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
A video was observed of a staff attacking a child which led to a physical altercation between the staff and child.		 —
3— 748.111(14) - Child-care policy - Procedures for routine and emergency diagnosis, including treatment of medical and dental problems
During the application inspection the policy for medical care was missing. The mock file did not show the children had received medication from the date they entered the facility. Pregnancy needs for girls was void since the agency doesn't take females. Primary medical needs not listed in the policy.		 —
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 used derogatory language when addressing a child's behavior.		 —
3— 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Six reviewed medication records to not document the reason the child's medication is prescribed.		 —
3— 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Licensing did not have access to all active records during a monitoring inspection.		 —
2— 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children
The recreational calendar reviewed during inspection does not include both indoor and outdoor daily activities.		 —
4— 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
Seven medication records reviewed did not have an accurate pill count documented.		 —
4— 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Caregivers failed to properly supervise a child in care who was exhibiting high risk behaviors.		 —
5— 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint
Child in care was face down during restraint.		 —
4— 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units
The smoke detectors were sounding off on both levels . The detectors needed to have new batteries.		 Yes
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 in care displayed warning signs to a staff member and a screening being done was not recommended.		 —
3— 748.111(14) - Child-care policy - Procedures for routine and emergency diagnosis, including treatment of medical and dental problems
During the application inspection the policy for medical care was missing. The mock file did not show the children had received medication from the date they entered the facility. Pregnancy needs for girls was void since the agency doesn't take females. Primary medical needs not listed in the policy.		 —
4— 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
Medication that was administered to a youth in care on 5/5/2025 at 7:00A was not recorded on the medication log until 5/6/2025 at 1:00P. Operation staff admitted during an inspection they failed to record administration of medication timely.		 Yes
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's right to be free of neglectful supervision was not upheld when staff did not implement policy and demonstrated disregard by leaving children in care unattended in the operation's van with the keys in addition to allowing the child to operate the vehicle. These actions demonstrated negligence. This standard was found deficient as part of a DFPS Investigation.		 —
3— 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
Multiple active employee records have an incomplete/unnotarized Licensing Affidavit for Applicants for Employment form.		 —
3— 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Six reviewed medication records to not document the reason the child's medication is prescribed.		 —
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 used derogatory language when addressing a child's behavior.		 —
5— 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff should manage the children effectively and try and prevent situations. Staff are allowing children that were involved in a physical altercation share a room.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
In review of a child service plan, the last vision screening was completed on 11/4/2024, however her last screening was completed on 11/5/2025.		 Yes
3— 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
The author of an incident report, failed to document her involvement during a restraint of a child in care.		 —
4— 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours
Based on interviews and documentation, an employee was found to be sleeping while taking care of children.		 —
5— 748.3601(9) - Swimming Pool-swimming area rules & emergency procedures must be posted at the swimming area & explained to the children
There were no rules or emergency procedures posted in the pool area.		 —
3— 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Six medication records for children were observed without documentation of the prescribing physician.		 —
4— 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use
During the following application the agency didn't list the types of restraints that will be administered. A complete description of the TBRI information is needed.		 —
3— 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
Multiple active employee files reviewed have no record of a Pre-Employment Affidavit for Applicants for Employment form.		 —
4— 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff did not exercise prudent judgement when they allowed a child in care to operate a motor vehicle without a valid driver's license.		 —
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 documentation of any practiced severe weather drills in the past 6 months.		 —
5— 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff allowed a child to drive without staff supervision and left the van keys accessible, which later led to the van being stolen and crashed.		 —
1— 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate. At minimum must give copy to child 14 years and older
A child did not receive a copy of their initial service plan.		 —
4— 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff was observed inappropriately disciplining a child and attempting to place the child in a chokehold, this also included pushing and shoving the child to the ground.		 —
4— 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
Review of kids in care medication administration records revealed medications were not administered as prescribed.		 —
4— 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
There were damage found with the fencing, security of the perimeter and damaged outside.		 —
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 was involved in physical altercation which resulted in two black eyes and no medical care was sought.		 —
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
On 8/19/2025 a youth in care was transported to the hospital for medical evaluation for a hand injury. After clearance the youth was admitted to a psychiatric hospital for suicidal ideations & unsafe behaviors. This incident was not reported to Licensing.		 —
2— 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times
The permit was not posted anywhere at the operation.		 Yes
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The records/documentation were not consistent, accurate, or completely filled out on the paperwork from the operation during the inspection.		 —
1— 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event
Documentation to be reviewed were not in the youth's files timely although they were able to be provided.		 —
5— 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting
Staff was observed hitting and punching a child on video.		 —
5— 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
A video was observed of a staff attacking a child which led to a physical altercation between the staff and child.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
An incident report was found to have inaccurate information. The date of the incident was incorrect. In addition, a caregiver named in the report was not present on the day of the incident.		 —
5— 748.3603(f) - Swimming-Fence gates to outdoor pool must have self-closing/self-latching hardware 60 inches from the ground and must be locked when pool not in use
The gate surrounding the pool did not have self-latching hardware.		 —
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
A staff member did not complete the required refresher EBI training.		 —
4— 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings
There were no emergency evacuation diagrams posted in the home.		 —
3— 748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement
During the investigation it was found that a child's high risk behavior was identified at admission and a safety plan was not implemented to address that behavior.		 —
3— 748.311 - Serious Incident Documentation-Documented in written report
Serious incident report was missing documentation, the incident of how a child in care received two black eyes was not documented.		 —
3— 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Staff did not follow the operation's policy when they left children unattended in the van with the keys.		 —
4— 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
Child in care was given a different dose of medication as prescribed.		 —
4— 748.3233(b)(4)(E) - Evacuation-Emergency evacuation & relocation diagram includes 2 exit routes that are not doors or windows that require key to open from inside
The emergency diagram showed three downstairs emergency exits that were locked from the inside, required a key to open, and two of the three exits were a pathway through the kitchen.		 —
5— 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
Staff was observed on video attempting to wrap their arms around a child's neck. Staff was also observed pushing the child to the floor.		 —
3— 748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The operation failed to timely input quarterly date for EBI's for the 4th quarter of 2025 and the first quarter of 2026.		 —
2— 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the investigation it was found that a child's service plan was not completed timely.		 —
3— 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
2 staff files and 1 child file were reviewed. Each file contained paperwork that was incomplete.		 —
2— 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
A youth's initial service plan wasn't developed timely after their admission.		 —
3— 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
Multiple active employee files reviewed have no record of a Pre-Employment Affidavit for Applicants for Employment form.		 —
2— 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the investigation it was found that a child's service plan was not completed timely.		 —

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

Inspections (168)

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

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