Texas › Fresno › Tshepang Center Residential Treatment Center, LLC

Tshepang Center Residential Treatment Center, LLC

Child care center · 603 E DALLAS ST, Fresno, TX 77545-8201 · License 1786589

0Compliance score
Poor

Capacity 10. 7-17

Violation history (272)

Severity	Date	Standard / narrative	Corrected
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
2	—	748.503 - Minimum qualifications for employees-Must provide supporting information and translation for documentation of education received outside US. One employee record did not contain proof of education.	—
3	—	748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.	—
2	—	748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.	—
2	—	748.3351(2) - Interior Space-Provide personal storage space in the child's bedroom for each child's clothing and belongings At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.	Yes
2	—	748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child There was no post discussion documentation available for review.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.	—
5	—	748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.	—
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.	—
5	—	748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training. Staff files was reviewed and two out four files didn't obtain a current annual suicide training.	—
4	—	748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision Children in care were able to smoke on the operations property while being left unsupervised.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Two children confirmed that they experienced mistreatment by staff during their time in care.	—
1	—	748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan During the inspection it was found that a child's service plan did not have signatures of service planning team members.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Children in care confirmed three staff have been observed sleep during overnight awake staff duties.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...	—
4	—	748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Based on the video observed, there was no de-escalation methods used prior to restraint.	—
4	—	748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid Staff files were reviewed and CPR training expired on 10/11/25, additional record ddid not contain CPR/1st Aid.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Medication records were reviewed to not be accurately filled out with dates and the count.	—
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 During a visit to the operation there were eight children observed to be present with caregiver. Three of the present children require a one to one supervision level.	—
3	—	748.363(11) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months. Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.	Yes
5	—	748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking One employee record reviewed contained an expired CPR/First aid certificate.	—
3	—	748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.	—
1	—	748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. One employee record reviewed did not contain information obtained from a reference.	—
3	—	748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references. Staff files was reviewed and there was no proof of referrences for two out of the four files that were selected.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair While conducting a walk through, two beds were observed to have collapsed.	—
3	—	748.101(2)(B) - Plans to submit - Fiscal plan - documentation to reserve funds or available credit at least equal to operating costs for first 3 months During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.	—
3	—	748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling Staff files was reviewed and two out of four files didn't obtain proof of diploma or G.E.D.	—
3	—	748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.	—
2	—	748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation The operation does not have documented information for when any safety drills have been conducted.	—
5	—	748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.	—
3	—	748.363(8) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies Two employee records did not contain a statement indicating that they have read the policies.	—
1	—	748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities During a review of the service plan it does not identfy the normalcy decision maker in the team.	—
3	—	748.363(11) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months. Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.	Yes
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
3	—	748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Two children confirmed that they experienced mistreatment by staff during their time in care.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.	—
3	—	748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.	—
2	—	748.503 - Minimum qualifications for employees-Must provide supporting information and translation for documentation of education received outside US. One employee record did not contain proof of education.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
1	—	748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.	—
1	—	748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan During the inspection it was found that a child's service plan did not have signatures of service planning team members.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair While conducting a walk through, two beds were observed to have collapsed.	—
4	—	748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Based on the video observed, there was no de-escalation methods used prior to restraint.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...	—
2	—	748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.	—
4	—	748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision Children in care were able to smoke on the operations property while being left unsupervised.	—
5	—	748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.	—
5	—	748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking One employee record reviewed contained an expired CPR/First aid certificate.	—
3	—	748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.	—
5	—	748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training. Staff files was reviewed and two out four files didn't obtain a current annual suicide training.	—
1	—	748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities During a review of the service plan it does not identfy the normalcy decision maker in the team.	—
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.	—
2	—	748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation The operation does not have documented information for when any safety drills have been conducted.	—
5	—	748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.	—
3	—	748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling Staff files was reviewed and two out of four files didn't obtain proof of diploma or G.E.D.	—
3	—	748.101(2)(B) - Plans to submit - Fiscal plan - documentation to reserve funds or available credit at least equal to operating costs for first 3 months During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.	—
3	—	748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references. Staff files was reviewed and there was no proof of referrences for two out of the four files that were selected.	—
4	—	748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid Staff files were reviewed and CPR training expired on 10/11/25, additional record ddid not contain CPR/1st Aid.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Children in care confirmed three staff have been observed sleep during overnight awake staff duties.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Medication records were reviewed to not be accurately filled out with dates and the count.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. One employee record reviewed did not contain information obtained from a reference.	—
3	—	748.363(8) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies Two employee records did not contain a statement indicating that they have read the policies.	—
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 During a visit to the operation there were eight children observed to be present with caregiver. Three of the present children require a one to one supervision level.	—
2	—	748.3351(2) - Interior Space-Provide personal storage space in the child's bedroom for each child's clothing and belongings At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.	Yes
2	—	748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child There was no post discussion documentation available for review.	—
3	—	748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.	—
1	—	748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities During a review of the service plan it does not identfy the normalcy decision maker in the team.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
3	—	748.363(11) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months. Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.	Yes
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...	—
5	—	748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training. Staff files was reviewed and two out four files didn't obtain a current annual suicide training.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Two children confirmed that they experienced mistreatment by staff during their time in care.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair While conducting a walk through, two beds were observed to have collapsed.	—
3	—	748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references. Staff files was reviewed and there was no proof of referrences for two out of the four files that were selected.	—
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.	—
2	—	748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Medication records were reviewed to not be accurately filled out with dates and the count.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Children in care confirmed three staff have been observed sleep during overnight awake staff duties.	—
2	—	748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child There was no post discussion documentation available for review.	—
4	—	748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid Staff files were reviewed and CPR training expired on 10/11/25, additional record ddid not contain CPR/1st Aid.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The operation did not complete a health inspection timely.	—
5	—	748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking One employee record reviewed contained an expired CPR/First aid certificate.	—
3	—	748.101(2)(B) - Plans to submit - Fiscal plan - documentation to reserve funds or available credit at least equal to operating costs for first 3 months During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.	—
3	—	748.363(8) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies Two employee records did not contain a statement indicating that they have read the policies.	—
2	—	748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation The operation does not have documented information for when any safety drills have been conducted.	—
1	—	748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan During the inspection it was found that a child's service plan did not have signatures of service planning team members.	—
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 During a visit to the operation there were eight children observed to be present with caregiver. Three of the present children require a one to one supervision level.	—
4	—	748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision Children in care were able to smoke on the operations property while being left unsupervised.	—
4	—	748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Based on the video observed, there was no de-escalation methods used prior to restraint.	—
1	—	748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. One employee record reviewed did not contain information obtained from a reference.	—
5	—	748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.	—
3	—	748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.	—
3	—	748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.	—
3	—	748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling Staff files was reviewed and two out of four files didn't obtain proof of diploma or G.E.D.	—
5	—	748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.	—

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

Inspections (136)

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

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