Child care center ·
11949 ESCARPMENT BLVD, Austin, TX 78739-1549 ·
License 1752756
Capacity 32. 13-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint
Child files reviewed did not indicate any known contraindications to the use of restraints during their pre or post admission documentation. |
Yes |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During the investigation, it was found that one (1) staff who was reported to be an employee of the operation has a pending fingerprint background check but has been working at the operation on an as needed basis as a nurse. Another staff who was reported to be a personal trainer on campus for the children in care who is considered a volunteer of the operation did not have a background check. |
— |
| 1 | — |
748.1217(b)(14) - Admission Assessment-At admission, must include parent's expectations for placement, duration of placement, & family involvement
Operation does not have goals or expectations from the parent in their current admission procedure/documentation. |
Yes |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
During an inspection, the operation was not able to access training documentation for 2 of 3 staff and was not able to access a notarized affidavit for 1 of 3 staff. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
4 out of 4 records reviewed contained no section for addtional information for child runaways. |
— |
| 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 was able to gain access to the operation's medication storage area and obtain another child's prescription medication without any staff witnessing the incident. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Video footage obtained revealed two children were in a bathroom for approximately 12 minutes and engaged in inappropriate activity. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Two child records reviewed were missing items in children's rights. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed during the walk through multiple beds did not have mattress covers on mattresses, that were not waterproof. |
— |
| 2 | — |
748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results
1 of 2 child records did not have the dental examination results. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Two staff members were made unaware of 2 residents leaving the home and walking around the facility during their bedtime for about an hour. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The operation did not include the name or information of the person the child was discharged to on the discharge summary. |
— |
| 4 | — |
748.3101(1) - Fire Inspection-Must have fire inspection before initial permit issued
Fire Inspection was not provided. |
— |
| 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
When requesting drug tests not all staff was drug tested. HR is allowing staff to set up dates to get drug tested by today and get drug tested by the end of June. |
— |
| 4 | — |
748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication
During the investigation, it was found that a direct care staff administered a prescription medication to a teenager in care that was requested by the child, but this medication was not supposed to be administered to this child because there was no health care professional order for the prescription medication. There were no reported injuries, adverse actions or drug reactions for the child that would have caused harm. It was also found that children in care have been administered two different as needed prescription medications from the same prescription bottle prescribed to the operation as a whole. |
— |
| 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
Video footage at school revealed there were there were initially 4 staff with 18 kids however 1 staff member and 1 child left leaving the operation out of ratio at 17 kids to 3 staff. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
1 out of 4 staff records reviewed was missing their affidavit in their file. |
— |
| 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
Child in care placed at the operation for 55 days with no TB test. |
— |
| 1 | — |
748.1209(b)(8) - Child Orientation-Include policies on the religious program and practices
Two out of two child files reviewed reflected it did not include operation policies on their religious program and practices as well as gifts. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
Bedroom facing the pool has a metal structure that can be hazardous for a child if they fall over the balcony. |
— |
| 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
Several fire extinguishers were observed to have low pressure or in the red, no documentation of service date, and one fire extinguisher was last serviced in October 2018, |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
The serious incident report was missing the operation's full physical address (section 1); five staff names who were involved and/or assisted (section 4) with the incident; witnesses (children/staff) who may have seen or heard the incident (section 5)]; and the child's reported suicidal ideation/suicidal comment(s) and time child was transported to the hospital (section 7). |
— |
| 4 | — |
748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected
4 out of 4 records were missing the vision and hearing exam in the children's record's. |
— |
| 2 | — |
748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements
4 out of 4 records did not have medical, and dental records documented in the child's record. |
— |
| 3 | — |
748.311(10) - Serious Incident Documentation-Includes resolution of the incident
4 out of 4 incident reports reviewed did not contain a resolution section. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
Three out of four vehicles used to transport children had expired inspection stickers. Two vehicle's inspection stickers expired in May 2024 and the third expired in September 2024. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The operation did not include the address, telephone number, or relationship of the person to whom the child was discharged to on the discharge summary. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Three mattresses were missing the cover. |
Yes |
| 4 | — |
748.1205(a)(7) - Admission Documentation-Includes child's immunization record
4 out of 4 records did not have the immunization record documented in the resident's record. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
A child in care was able to obtain another child's prescription medication due to the medication storage area being left open and unlocked and unattended by staff. |
— |
| 3 | — |
748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
Copy of Clinical Social Worker License not in personnel record. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
Staff file reviewed indicated CPR/First Aid was completed after 90 days of employment and had access to children in care. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
Four employees do not have cleared fingerprint results from the CBCU and have began employment. Three of four of the employees work directly with the children. One of four of the staff's background checks is showing as inactive in CLASS. |
— |
| 5 | — |
748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583
1 out of 2 staff records reviewed that will be working with residents directly did not have a copy of their TB results. |
— |
| 1 | — |
748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history
4 out of 4 records did not contain the neonatal history recorded in the resident's chart. |
— |
| 4 | — |
748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued
Sanitation Inspection was not provided. |
— |
| 3 | — |
748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation
2 out of 2 documents reviewed showed medications for clients were taken past the hour scheduled to be taken. |
— |
| 2 | — |
748.1345(1)(B) - Initial Service Plan-For ED and ASD treatment services, PLSP must review identified needs and plan for treatment based on child's diagnoses
The operation continued to care for a teenager in care who has history of trauma related to human trafficking as documented in the child's Biopsychosocial Assessment, however the operation doesn't provide this service. |
— |
| 1 | — |
748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care
Placement agreement currently in place did not indicate the reason and length of time when child is placed at the operation. |
Yes |
| 4 | — |
748.153(3)(B) - Notification - New controlling person
New director not added into controlling persons withing 24hrs of DOH. |
— |
| 5 | — |
748.3603(j) - Doors from operation leading to pool area must have lock that can only be opened by adult unless lock violates fire code and documentation is on file
Multiple doors leading to the swimming pool do not have a lock. |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
Observation during walkthrough of operation revealed fire extinguishers in the three homes and the school to have been last inspected December 2022. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
One staff who has a Provisional background check with conditions was reported to have been working at the operation with direct access to children in care and administering medications to children in care, this staff was working at the operation on 1/27/23. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
The 2 doors leading to the water heater were not locked. 1 out of 2 doors that contain electrical wires were not locked. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
1 out of 2 records reviewed contained no notarized affidavit. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During interviews and documentation it was determined that the operations secured items policy is that staff members are to hand the residents any checked out items. A child in care was allowed to retrieve secured items and was able to grab a razor without staff knowledge. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
Bedroom facing the pool has a metal structure that can be hazardous for a child if they fall over the balcony. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Two child records reviewed were missing items in children's rights. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Video footage obtained revealed two children were in a bathroom for approximately 12 minutes and engaged in inappropriate activity. |
— |
| 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
Several fire extinguishers were observed to have low pressure or in the red, no documentation of service date, and one fire extinguisher was last serviced in October 2018, |
— |
| 5 | — |
748.3603(j) - Doors from operation leading to pool area must have lock that can only be opened by adult unless lock violates fire code and documentation is on file
Multiple doors leading to the swimming pool do not have a lock. |
— |
| 4 | — |
748.1205(a)(7) - Admission Documentation-Includes child's immunization record
4 out of 4 records did not have the immunization record documented in the resident's record. |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
Observation during walkthrough of operation revealed fire extinguishers in the three homes and the school to have been last inspected December 2022. |
— |
| 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
Video footage at school revealed there were there were initially 4 staff with 18 kids however 1 staff member and 1 child left leaving the operation out of ratio at 17 kids to 3 staff. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The operation did not include the address, telephone number, or relationship of the person to whom the child was discharged to on the discharge summary. |
— |
| 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
Child in care placed at the operation for 55 days with no TB test. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Three mattresses were missing the cover. |
Yes |
| 3 | — |
748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
Copy of Clinical Social Worker License not in personnel record. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
Three out of four vehicles used to transport children had expired inspection stickers. Two vehicle's inspection stickers expired in May 2024 and the third expired in September 2024. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
A child in care was able to obtain another child's prescription medication due to the medication storage area being left open and unlocked and unattended by staff. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Two staff members were made unaware of 2 residents leaving the home and walking around the facility during their bedtime for about an hour. |
— |
| 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 was able to gain access to the operation's medication storage area and obtain another child's prescription medication without any staff witnessing the incident. |
— |
| 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
When requesting drug tests not all staff was drug tested. HR is allowing staff to set up dates to get drug tested by today and get drug tested by the end of June. |
— |
| 4 | — |
748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint
Child files reviewed did not indicate any known contraindications to the use of restraints during their pre or post admission documentation. |
Yes |
| 4 | — |
748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication
During the investigation, it was found that a direct care staff administered a prescription medication to a teenager in care that was requested by the child, but this medication was not supposed to be administered to this child because there was no health care professional order for the prescription medication. There were no reported injuries, adverse actions or drug reactions for the child that would have caused harm. It was also found that children in care have been administered two different as needed prescription medications from the same prescription bottle prescribed to the operation as a whole. |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
The serious incident report was missing the operation's full physical address (section 1); five staff names who were involved and/or assisted (section 4) with the incident; witnesses (children/staff) who may have seen or heard the incident (section 5)]; and the child's reported suicidal ideation/suicidal comment(s) and time child was transported to the hospital (section 7). |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
One staff who has a Provisional background check with conditions was reported to have been working at the operation with direct access to children in care and administering medications to children in care, this staff was working at the operation on 1/27/23. |
— |
| 4 | — |
748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected
4 out of 4 records were missing the vision and hearing exam in the children's record's. |
— |
| 5 | — |
748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583
1 out of 2 staff records reviewed that will be working with residents directly did not have a copy of their TB results. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The operation did not include the name or information of the person the child was discharged to on the discharge summary. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
The 2 doors leading to the water heater were not locked. 1 out of 2 doors that contain electrical wires were not locked. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
During an inspection, the operation was not able to access training documentation for 2 of 3 staff and was not able to access a notarized affidavit for 1 of 3 staff. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
1 out of 4 staff records reviewed was missing their affidavit in their file. |
— |
| 2 | — |
748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements
4 out of 4 records did not have medical, and dental records documented in the child's record. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
Four employees do not have cleared fingerprint results from the CBCU and have began employment. Three of four of the employees work directly with the children. One of four of the staff's background checks is showing as inactive in CLASS. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed during the walk through multiple beds did not have mattress covers on mattresses, that were not waterproof. |
— |
| 3 | — |
748.311(10) - Serious Incident Documentation-Includes resolution of the incident
4 out of 4 incident reports reviewed did not contain a resolution section. |
— |
| 2 | — |
748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results
1 of 2 child records did not have the dental examination results. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During the investigation, it was found that one (1) staff who was reported to be an employee of the operation has a pending fingerprint background check but has been working at the operation on an as needed basis as a nurse. Another staff who was reported to be a personal trainer on campus for the children in care who is considered a volunteer of the operation did not have a background check. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
Staff file reviewed indicated CPR/First Aid was completed after 90 days of employment and had access to children in care. |
— |
| 4 | — |
748.153(3)(B) - Notification - New controlling person
New director not added into controlling persons withing 24hrs of DOH. |
— |
| 1 | — |
748.1209(b)(8) - Child Orientation-Include policies on the religious program and practices
Two out of two child files reviewed reflected it did not include operation policies on their religious program and practices as well as gifts. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
4 out of 4 records reviewed contained no section for addtional information for child runaways. |
— |
| 1 | — |
748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history
4 out of 4 records did not contain the neonatal history recorded in the resident's chart. |
— |
| 2 | — |
748.1345(1)(B) - Initial Service Plan-For ED and ASD treatment services, PLSP must review identified needs and plan for treatment based on child's diagnoses
The operation continued to care for a teenager in care who has history of trauma related to human trafficking as documented in the child's Biopsychosocial Assessment, however the operation doesn't provide this service. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During interviews and documentation it was determined that the operations secured items policy is that staff members are to hand the residents any checked out items. A child in care was allowed to retrieve secured items and was able to grab a razor without staff knowledge. |
— |
| 4 | — |
748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued
Sanitation Inspection was not provided. |
— |
| 4 | — |
748.3101(1) - Fire Inspection-Must have fire inspection before initial permit issued
Fire Inspection was not provided. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
1 out of 2 records reviewed contained no notarized affidavit. |
— |
| 3 | — |
748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation
2 out of 2 documents reviewed showed medications for clients were taken past the hour scheduled to be taken. |
— |
| 1 | — |
748.1217(b)(14) - Admission Assessment-At admission, must include parent's expectations for placement, duration of placement, & family involvement
Operation does not have goals or expectations from the parent in their current admission procedure/documentation. |
Yes |
| 1 | — |
748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care
Placement agreement currently in place did not indicate the reason and length of time when child is placed at the operation. |
Yes |
| 4 | — |
748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication
During the investigation, it was found that a direct care staff administered a prescription medication to a teenager in care that was requested by the child, but this medication was not supposed to be administered to this child because there was no health care professional order for the prescription medication. There were no reported injuries, adverse actions or drug reactions for the child that would have caused harm. It was also found that children in care have been administered two different as needed prescription medications from the same prescription bottle prescribed to the operation as a whole. |
— |
| 1 | — |
748.1217(b)(14) - Admission Assessment-At admission, must include parent's expectations for placement, duration of placement, & family involvement
Operation does not have goals or expectations from the parent in their current admission procedure/documentation. |
Yes |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Two child records reviewed were missing items in children's rights. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
The 2 doors leading to the water heater were not locked. 1 out of 2 doors that contain electrical wires were not locked. |
— |
| 2 | — |
748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results
1 of 2 child records did not have the dental examination results. |
— |
| 4 | — |
748.153(3)(B) - Notification - New controlling person
New director not added into controlling persons withing 24hrs of DOH. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
Staff file reviewed indicated CPR/First Aid was completed after 90 days of employment and had access to children in care. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
4 out of 4 records reviewed contained no section for addtional information for child runaways. |
— |
160 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.