Capacity 14. 8-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
A staff file is missing documentation of a Pre-Employment Affidavit which is required to be certified prior to employment. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
One of four child medication records reviewed was missing documentation for a medication that was given to a child for one day/date. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
Employee record is missing the TB test, job description, and the performance evaluation. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
No serious incident report regarding the incident in question was provided during the investigation. |
— |
| 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
During the inspection, it was observed that the operation's vehicle did not have a required inspection or proper vehicle registration. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One of the child's records reviewed showed discrepancies in the medical appointment dates, with several forms listing dates that did not match the date signed by the medical provider. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
Three staff records reviewed did not contain accurate/completed pre-employment screenings. (2 were missing the screenings and 1 was not completed correctly) |
— |
| 3 | — |
748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826
Two dogs were observed on the property; however, the animal's vaccination records were not available for review. |
— |
| 4 | — |
748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health
One of the child records reviewed did not containt documentation of a completed hearing checkup since the child's placement on 12/11/24. Additionally, the most recent vision checkup was completed in April 2025, making it two months overdue. |
— |
| 5 | — |
745.509 - Licensed Operations Required Fees
Background check fee was delinquent as of inspection date. It was due on or before 12/31/24. |
— |
| 4 | — |
748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs
Two staff record reviewed indicated staff did not receive and/or meet the exemption of pre-service experience training. |
— |
| 3 | — |
748.3319(a) - Required Postings-Residential Treatment Center's must have "No Trespassing Signs" posted.
During the inspection, the rtc did not have the required no trespassing signs. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
An operation employee attempted to pass off a six month unauthorized absences evaluation dated for 6/30/25 as if it had been completed on 6-30-25. Evidenced was collected to prove that the form was not completed on 6-30-25. |
— |
| 4 | — |
748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations
A child in care was given the wrong medication and there is no evidence to show a health care professional was contacted. |
— |
| 3 | — |
748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
The operation did not complite a six month anauthorized absence evaluation in June 2025. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
A child in care was given the wrong medication and there is no documentation of the medication error. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
During the ANE investigation, it was determined that a caregiver got into a physical altercation with a child in care resulting in the child receiving injuries to his face and body. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation's policies include an address unrelated to this operation. The operation's policies state the children will attend a school district that is not in the area of the operation. |
— |
| 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.
Agency has not submitted their EBI data for the 1st quarter of 2025. |
— |
| 3 | — |
748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
Three out of three children records were observed to be missing. |
— |
| 4 | — |
748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation
During the inspection, the operation's emergency evacuation diagram did not include an escape route, a meeting location outside, or a shelter in place location inside the home. |
— |
| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
During the inspection, it was determined that the operation's vehicle did not start properly and did not appear ready to transport children. |
— |
| 4 | — |
748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.
The assessment did not have a space for trauma, immediate goals, determination of how the operation will meet the needs, maladaptive behavior, birth/neonatal history, or criminal history. Also, did not see a spot for the services that will be provided to child. |
— |
| 3 | — |
748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations
The office where active child records are stored was unlocked and provided access for anyone to enter the property and gain access to confidential information. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The job description in one workers personnel file has the name of an employee that is not employed or listed on the person's list of the operation. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation has been without a licensed Administrator for over 60 days. |
— |
| 3 | — |
748.453(a)(5) - Unauthorized Absence?Annual summary log must include the intake report number, if report was made to CCR or DFPS
The form was missing a spot for reporting to Licensing. The form was also missing a spot for gender and DOA. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
Eight beds were observed to be missing top sheets, and two beds were missing mattress pads. |
Yes |
| 2 | — |
748.1331(b)(1) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate treatment and care needs
The plan did not include the immediate treatment and care needs, as well as a designation of who will be responsible for the child. |
— |
| 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 record reviewed indicated that thestaff member did not complet the required 8 hours of EBI training before being included in the ratio. |
— |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
Child victim's preliminary service plan indicates he may not share a bedroom with another resident. Information obtained throughout the investigation indicates the child victim was sharing a bedroom on the day of the incident. |
— |
| 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
Schedule II psychotropic medications were observed stored in a locked cabinet inside the laundry room, which is located off the living room. This makes the medications accessible when the laundry room is in use, creating a potential safety risk. |
— |
| 3 | — |
748.363(4) - Personnel records-Personnel records-Include current job description.
One worker is missing a job description from their personnel file. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The deeper freezer in the kitchen does no have a thermometer to verify food is at the appropriate temperature. |
— |
| 2 | — |
748.1217(b)(13) - Admission Assessment-At admission, must include immediate goals of placement
One of the child records reviewed found the admission assessment and 72 hours service plan were completed 6 days after placement. Additionally, the following information was found missing from the admission assessment: -Immediate goals of placement -The child s understanding of the placement -The parent s expectations for placement -The child s social history -A description of the child s home environment and family functioning -The child s birth and neonatal history -The child s mental health and substance abuse history -The child s history of any other placements outside the child s home -The child s skills and special interests -The child s criminal history, if applicable |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
On 12-17-25 a monitoring inspection was conducted at the operation. The director restated that an Administrator has not been hired. |
— |
| 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
The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
Two child records reviewed did not include documentation of known or unknown allergies on the exterior of records or in a clearly visible location. |
— |
| 4 | — |
748.3301(h) - Physical Site-The building must be free of rodents and insects
Insects were observed in the living quarters of children in care and around the door frame of the backdoor. |
— |
| 4 | — |
748.1501(d) - Dental Care-must obtain follow-up dental work recommended by the dentist
Child in care, Aidan M., on October 3, was referred by Galaxia Dental to see an endodontist for a root canal to be completed on teeth #31 and #18. Per the recommendations, Aidan was to be prepped for the crown on the same teeth once the root canals were completed. No documentation shows that the root canals or crowns have been completed per the dentist's recommendation. |
— |
| 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
The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker. |
— |
| 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 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff allowed children to violate the operation's rules by allowing the children access into one another's bedroom closet with the closet door closed. It was founded that while the children were located inside the closet the children attempted to use a vape. |
— |
| 3 | — |
748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
The grounds of the operations were observed to have tall grass in the front yard and multiple bags of trash were observed in front of the apartment door. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
In bedroom room one, the bottom bunk did not have a mattress protector. A bed skirt was being used as a mattress protector. |
Yes |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation does not have a full-tine administrator. |
— |
| 2 | — |
748.153(2)(B) - Notification - At least 15 days in advance - Changes to floor plan
Operation staff made changes to the operations floor plan without providing notification. The second living room is now being utilized as an office space that children in care do not have access to. |
— |
| 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.
One of the child records reviewed found the suicide screening was not administered for March of 2025 as required. |
— |
| 4 | — |
748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units
The smoke detector in room 4 is flashing red and beeping. |
Yes |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During an inspection at the operation it was discovered that 15 year old biological daughter of an owner of the operation resides at the operation without an initial background check being submitted. |
— |
| 3 | — |
748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules
The policies submitted should follow the guidelines of minimum standards, but it should also be tailored to your operational needs/wants. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
One staff record reviewed indicated staff did not have a cleared TB screening prior to having contact with children in care. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
One of the child records reviewed found the initial service plan was not completed within 45 days of placement. Additionally, service plan was not dated and signed by child, parent, caregivers, and 2 PLSP as required. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
During the inspection, it was determined that the serious incident report did not include the address and phone number of the operation. |
— |
| 5 | — |
748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.
Three employee's personnel files have no documentation showing their completion of the annual training. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
Camera extensions were hanging over walls and cabinets. An orange extension cord, a basket of clothes and objects were on the floor in the common area. |
— |
| 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
Scheduled II psychotropic medications were observed in an unlocked cabinet during the visit. |
Yes |
| 3 | — |
748.2101(8) - Medication Storage & Destruction-remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access
The operation office is being used to store medication for a child in care who was discharged from the operation back around November 1 or 2. The medication was found in an unlocked closet and unlocked office, which provides access and accessibility to the medication, including other children in care. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
On 12-17-25 a monitoring inspection was conducted at the operation. The director restated that an Administrator has not been hired. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation's policies include an address unrelated to this operation. The operation's policies state the children will attend a school district that is not in the area of the operation. |
— |
| 4 | — |
748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs
Two staff record reviewed indicated staff did not receive and/or meet the exemption of pre-service experience training. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
An operation employee attempted to pass off a six month unauthorized absences evaluation dated for 6/30/25 as if it had been completed on 6-30-25. Evidenced was collected to prove that the form was not completed on 6-30-25. |
— |
| 3 | — |
748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
Three out of three children records were observed to be missing. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
One staff record reviewed indicated staff did not have a cleared TB screening prior to having contact with children in care. |
— |
| 3 | — |
748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
The operation did not complite a six month anauthorized absence evaluation in June 2025. |
— |
| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
During the inspection, it was determined that the operation's vehicle did not start properly and did not appear ready to transport children. |
— |
| 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 record reviewed indicated that thestaff member did not complet the required 8 hours of EBI training before being included in the ratio. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation does not have a full-tine administrator. |
— |
| 4 | — |
748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units
The smoke detector in room 4 is flashing red and beeping. |
Yes |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During an inspection at the operation it was discovered that 15 year old biological daughter of an owner of the operation resides at the operation without an initial background check being submitted. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
During the ANE investigation, it was determined that a caregiver got into a physical altercation with a child in care resulting in the child receiving injuries to his face and body. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
Camera extensions were hanging over walls and cabinets. An orange extension cord, a basket of clothes and objects were on the floor in the common area. |
— |
| 3 | — |
748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826
Two dogs were observed on the property; however, the animal's vaccination records were not available for review. |
— |
| 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 | — |
748.3301(h) - Physical Site-The building must be free of rodents and insects
Insects were observed in the living quarters of children in care and around the door frame of the backdoor. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
One of the child records reviewed found the initial service plan was not completed within 45 days of placement. Additionally, service plan was not dated and signed by child, parent, caregivers, and 2 PLSP as required. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The deeper freezer in the kitchen does no have a thermometer to verify food is at the appropriate temperature. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
During the inspection, it was determined that the serious incident report did not include the address and phone number of the operation. |
— |
| 4 | — |
748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health
One of the child records reviewed did not containt documentation of a completed hearing checkup since the child's placement on 12/11/24. Additionally, the most recent vision checkup was completed in April 2025, making it two months overdue. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
No serious incident report regarding the incident in question was provided during the investigation. |
— |
| 2 | — |
748.1331(b)(1) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate treatment and care needs
The plan did not include the immediate treatment and care needs, as well as a designation of who will be responsible for the child. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
Employee record is missing the TB test, job description, and the performance evaluation. |
— |
| 5 | — |
748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.
Three employee's personnel files have no documentation showing their completion of the annual training. |
— |
| 5 | — |
745.509 - Licensed Operations Required Fees
Background check fee was delinquent as of inspection date. It was due on or before 12/31/24. |
— |
| 4 | — |
748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation
During the inspection, the operation's emergency evacuation diagram did not include an escape route, a meeting location outside, or a shelter in place location inside the home. |
— |
| 2 | — |
748.1217(b)(13) - Admission Assessment-At admission, must include immediate goals of placement
One of the child records reviewed found the admission assessment and 72 hours service plan were completed 6 days after placement. Additionally, the following information was found missing from the admission assessment: -Immediate goals of placement -The child s understanding of the placement -The parent s expectations for placement -The child s social history -A description of the child s home environment and family functioning -The child s birth and neonatal history -The child s mental health and substance abuse history -The child s history of any other placements outside the child s home -The child s skills and special interests -The child s criminal history, if applicable |
— |
| 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
During the inspection, it was observed that the operation's vehicle did not have a required inspection or proper vehicle registration. |
— |
| 3 | — |
748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations
The office where active child records are stored was unlocked and provided access for anyone to enter the property and gain access to confidential information. |
— |
| 3 | — |
748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
A staff file is missing documentation of a Pre-Employment Affidavit which is required to be certified prior to employment. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
A child in care was given the wrong medication and there is no documentation of the medication error. |
— |
| 2 | — |
748.153(2)(B) - Notification - At least 15 days in advance - Changes to floor plan
Operation staff made changes to the operations floor plan without providing notification. The second living room is now being utilized as an office space that children in care do not have access to. |
— |
| 3 | — |
748.453(a)(5) - Unauthorized Absence?Annual summary log must include the intake report number, if report was made to CCR or DFPS
The form was missing a spot for reporting to Licensing. The form was also missing a spot for gender and DOA. |
— |
| 3 | — |
748.363(4) - Personnel records-Personnel records-Include current job description.
One worker is missing a job description from their personnel file. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The job description in one workers personnel file has the name of an employee that is not employed or listed on the person's list of the operation. |
— |
| 4 | — |
748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.
The assessment did not have a space for trauma, immediate goals, determination of how the operation will meet the needs, maladaptive behavior, birth/neonatal history, or criminal history. Also, did not see a spot for the services that will be provided to child. |
— |
| 4 | — |
748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations
A child in care was given the wrong medication and there is no evidence to show a health care professional was contacted. |
— |
| 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
The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker. |
— |
| 3 | — |
748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
The grounds of the operations were observed to have tall grass in the front yard and multiple bags of trash were observed in front of the apartment door. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation has been without a licensed Administrator for over 60 days. |
— |
| 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
The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker. |
— |
146 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.