Capacity 7. 7-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
Information regarding child in care unauthorized absence was not documented the incident report. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the inspection of the facility the thermometer in the refrigerator's freezer displayed a temperature of 3 degrees and food should be stored at 0 degrees. |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
One of two serious incident reports reviewed noted no witnesses listed on the report. |
— |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
During the review of children files, one of the three files did not have the child rights form signed within the allotted timeframe of 7 days as the date of admission was 06/16/2025 and the child rights were signed on 01/27/2026. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
An employee left their medication on a table in the activity room. |
— |
| 3 | — |
748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
Law Enforcement was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
A child in care ran away from the operation three times in two days; the operation only had documentation for two of the three incidents. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence - Debriefing includes where child went, who was w/ child, child activities & any other relevant info to their health & safety
Review of 1 of 2 unauthorized absence debrief forms was partially completed. The question specific to this minimum standard was not answered and does not document the child refused to answer this question. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Caregivers did not intervene during a physical altercation resulting in injury to a child. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child, with identified trafficking history, admitted to having a sexual encounter with a person after an unauthorized absence from the operation was not taken to be seen by medical personnel. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Medication was observed to have been removed from its original pharmacy containers and combined into a single package, which is not consistent with how it was dispensed by the pharmacy. |
— |
| 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 parent was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
Staff spat on a youth face. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
The operation's former Administrator is still serving in the capacity of and identifying themself as the Administrator of the operation. The identified Administrator was not present at the operation during CCI?s visits and a designee was not assigned. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
Medication logs were observed to list dosages as "1 Package" rather than reflecting the accurate dosage instructions provided by the pharmacy. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
During the DFPS investigation and subsequent transfer to HHS, video footage was reviewed regarding a child attacking a caregiver. The video footage shows the staff member pulling the child's hair, in defense, when being attacked. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Operation staff did not provide adequate supervision which allowed for child to tattoo themselves. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care obtained medications and self-harmed without the knowledge of staff members. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During the review of the employee file, it was noted that the required notarized employment affidavit was not present in the file at the time of the inspection. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One serious incident report reviewed improperly document there was no injury to child during an unauthorized absence however, the child did seek medical attention for foot injury during their absence. A second serious incident report reviewed incorrectly documented the child returned on August 10th however the child did not return until August 20th. |
— |
| 5 | — |
748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children
A youth in care under a special contract is supposed to have two staff members with them at all times. During operation inspections 4 children were left in the care of 1 staff member. Interviews conducted with youth in care also confirmed occasions of being left alone in the care of only 1 staff member. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
There was observed to be a broken window in one of the bedrooms that had exposed sharp glass pieces accessible from outside the operation. |
Yes |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver threatened to hit 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.
Licensing was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection of the facility the refrigerator was found to not have a thermometer present to gauge the temperature as well as both of the deep freezers present at the facility. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
Caregivers failed to seek medical treatment for a child injured during a physical altercation |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
The serious incident report for an unauthorized absence of a child in care did not include an update upon the child's return. |
— |
| 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.
Licensing was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
An employee left their medication on a table in the activity room. |
— |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
During the review of children files, one of the three files did not have the child rights form signed within the allotted timeframe of 7 days as the date of admission was 06/16/2025 and the child rights were signed on 01/27/2026. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection of the facility the refrigerator was found to not have a thermometer present to gauge the temperature as well as both of the deep freezers present at the facility. |
— |
| 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 parent was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
Caregivers failed to seek medical treatment for a child injured during a physical altercation |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
Information regarding child in care unauthorized absence was not documented the incident report. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Medication was observed to have been removed from its original pharmacy containers and combined into a single package, which is not consistent with how it was dispensed by the pharmacy. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During the review of the employee file, it was noted that the required notarized employment affidavit was not present in the file at the time of the inspection. |
— |
| 5 | — |
748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children
A youth in care under a special contract is supposed to have two staff members with them at all times. During operation inspections 4 children were left in the care of 1 staff member. Interviews conducted with youth in care also confirmed occasions of being left alone in the care of only 1 staff member. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
The serious incident report for an unauthorized absence of a child in care did not include an update upon the child's return. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
Medication logs were observed to list dosages as "1 Package" rather than reflecting the accurate dosage instructions provided by the pharmacy. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the inspection of the facility the thermometer in the refrigerator's freezer displayed a temperature of 3 degrees and food should be stored at 0 degrees. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence - Debriefing includes where child went, who was w/ child, child activities & any other relevant info to their health & safety
Review of 1 of 2 unauthorized absence debrief forms was partially completed. The question specific to this minimum standard was not answered and does not document the child refused to answer this question. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver threatened to hit a child in care. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care obtained medications and self-harmed without the knowledge of staff members. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Caregivers did not intervene during a physical altercation resulting in injury to a child. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
The operation's former Administrator is still serving in the capacity of and identifying themself as the Administrator of the operation. The identified Administrator was not present at the operation during CCI?s visits and a designee was not assigned. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Operation staff did not provide adequate supervision which allowed for child to tattoo themselves. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One serious incident report reviewed improperly document there was no injury to child during an unauthorized absence however, the child did seek medical attention for foot injury during their absence. A second serious incident report reviewed incorrectly documented the child returned on August 10th however the child did not return until August 20th. |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
One of two serious incident reports reviewed noted no witnesses listed on the report. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
There was observed to be a broken window in one of the bedrooms that had exposed sharp glass pieces accessible from outside the operation. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child, with identified trafficking history, admitted to having a sexual encounter with a person after an unauthorized absence from the operation was not taken to be seen by medical personnel. |
— |
| 3 | — |
748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
Law Enforcement was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
Staff spat on a youth face. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
A child in care ran away from the operation three times in two days; the operation only had documentation for two of the three incidents. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
During the DFPS investigation and subsequent transfer to HHS, video footage was reviewed regarding a child attacking a caregiver. The video footage shows the staff member pulling the child's hair, in defense, when being attacked. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence - Debriefing includes where child went, who was w/ child, child activities & any other relevant info to their health & safety
Review of 1 of 2 unauthorized absence debrief forms was partially completed. The question specific to this minimum standard was not answered and does not document the child refused to answer this question. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
The operation's former Administrator is still serving in the capacity of and identifying themself as the Administrator of the operation. The identified Administrator was not present at the operation during CCI?s visits and a designee was not assigned. |
— |
| 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.
Licensing was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
During the review of children files, one of the three files did not have the child rights form signed within the allotted timeframe of 7 days as the date of admission was 06/16/2025 and the child rights were signed on 01/27/2026. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care obtained medications and self-harmed without the knowledge of staff members. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Caregivers did not intervene during a physical altercation resulting in injury to a child. |
— |
| 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 parent was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During the review of the employee file, it was noted that the required notarized employment affidavit was not present in the file at the time of the inspection. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
The serious incident report for an unauthorized absence of a child in care did not include an update upon the child's return. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
Information regarding child in care unauthorized absence was not documented the incident report. |
— |
| 3 | — |
748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
Law Enforcement was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the inspection of the facility the thermometer in the refrigerator's freezer displayed a temperature of 3 degrees and food should be stored at 0 degrees. |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
One of two serious incident reports reviewed noted no witnesses listed on the report. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection of the facility the refrigerator was found to not have a thermometer present to gauge the temperature as well as both of the deep freezers present at the facility. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
During the DFPS investigation and subsequent transfer to HHS, video footage was reviewed regarding a child attacking a caregiver. The video footage shows the staff member pulling the child's hair, in defense, when being attacked. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
There was observed to be a broken window in one of the bedrooms that had exposed sharp glass pieces accessible from outside the operation. |
Yes |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Medication was observed to have been removed from its original pharmacy containers and combined into a single package, which is not consistent with how it was dispensed by the pharmacy. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
Caregivers failed to seek medical treatment for a child injured during a physical altercation |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Operation staff did not provide adequate supervision which allowed for child to tattoo themselves. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child, with identified trafficking history, admitted to having a sexual encounter with a person after an unauthorized absence from the operation was not taken to be seen by medical personnel. |
— |
| 5 | — |
748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children
A youth in care under a special contract is supposed to have two staff members with them at all times. During operation inspections 4 children were left in the care of 1 staff member. Interviews conducted with youth in care also confirmed occasions of being left alone in the care of only 1 staff member. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
Staff spat on a youth face. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
A child in care ran away from the operation three times in two days; the operation only had documentation for two of the three incidents. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
Medication logs were observed to list dosages as "1 Package" rather than reflecting the accurate dosage instructions provided by the pharmacy. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One serious incident report reviewed improperly document there was no injury to child during an unauthorized absence however, the child did seek medical attention for foot injury during their absence. A second serious incident report reviewed incorrectly documented the child returned on August 10th however the child did not return until August 20th. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver threatened to hit a child in care. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
An employee left their medication on a table in the activity room. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
During the DFPS investigation and subsequent transfer to HHS, video footage was reviewed regarding a child attacking a caregiver. The video footage shows the staff member pulling the child's hair, in defense, when being attacked. |
— |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
During the review of children files, one of the three files did not have the child rights form signed within the allotted timeframe of 7 days as the date of admission was 06/16/2025 and the child rights were signed on 01/27/2026. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
Caregivers failed to seek medical treatment for a child injured during a physical altercation |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One serious incident report reviewed improperly document there was no injury to child during an unauthorized absence however, the child did seek medical attention for foot injury during their absence. A second serious incident report reviewed incorrectly documented the child returned on August 10th however the child did not return until August 20th. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care obtained medications and self-harmed without the knowledge of staff members. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
An employee left their medication on a table in the activity room. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
Information regarding child in care unauthorized absence was not documented the incident report. |
— |
| 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.
Licensing was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child, with identified trafficking history, admitted to having a sexual encounter with a person after an unauthorized absence from the operation was not taken to be seen by medical personnel. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During the review of the employee file, it was noted that the required notarized employment affidavit was not present in the file at the time of the inspection. |
— |
| 3 | — |
748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the child?s return.
The serious incident report for an unauthorized absence of a child in care did not include an update upon the child's return. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the inspection of the facility the thermometer in the refrigerator's freezer displayed a temperature of 3 degrees and food should be stored at 0 degrees. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection of the facility the refrigerator was found to not have a thermometer present to gauge the temperature as well as both of the deep freezers present at the facility. |
— |
| 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 parent was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
A child in care ran away from the operation three times in two days; the operation only had documentation for two of the three incidents. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Medication was observed to have been removed from its original pharmacy containers and combined into a single package, which is not consistent with how it was dispensed by the pharmacy. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Caregivers did not intervene during a physical altercation resulting in injury to a child. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Operation staff did not provide adequate supervision which allowed for child to tattoo themselves. |
— |
| 3 | — |
748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)
One of two serious incident reports reviewed noted no witnesses listed on the report. |
— |
112 inspection record(s) on file from TX-HHSC.