Capacity 11. 6-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment. However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022. Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement. Similar discrepancies were also observed in the preliminary service plan. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation. |
— |
| 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.
The unauthorized absence of two children in care was not reported timely. |
— |
| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
A staff member disclosed to law enforcement that a child was restrained with their hands behind their back. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
An admission assessment was observed to only have the resident's name and date. |
— |
| 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
The medication storage cabinet was observed unlocked during the investigation inspection. |
— |
| 3 | — |
748.709(c) - Name of each designated person must be documented on the face sheet of the child's record
Resident face sheet indicates a terminated employee is the normalcy designee. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child's service plan requires 24-hour staff supervision at all times; however, the operation was not implementing the supervision requirements as documented. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee that was no longer employeed since the beginning of May still shows active. |
— |
| 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.
Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
It was determined staff showed as active status since 03/30/25, however this staff was never employed by the operation |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child who is to be supervised 1:1 was permitted to leave the facility without staff supervision pursuant to an agreed upon two-hour check in agreement. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection. The operation must address and correct all identified code violations to achieve compliance. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
An admission assessment was observed to only have the resident's name and date. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child who is to be supervised 1:1 was permitted to leave the facility without staff supervision pursuant to an agreed upon two-hour check in agreement. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child's service plan requires 24-hour staff supervision at all times; however, the operation was not implementing the supervision requirements as documented. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment. However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022. Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement. Similar discrepancies were also observed in the preliminary service plan. |
— |
| 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.
Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence. |
— |
| 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.
The unauthorized absence of two children in care was not reported timely. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection. The operation must address and correct all identified code violations to achieve compliance. |
— |
| 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
The medication storage cabinet was observed unlocked during the investigation inspection. |
— |
| 3 | — |
748.709(c) - Name of each designated person must be documented on the face sheet of the child's record
Resident face sheet indicates a terminated employee is the normalcy designee. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
It was determined staff showed as active status since 03/30/25, however this staff was never employed by the operation |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee that was no longer employeed since the beginning of May still shows active. |
— |
| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
A staff member disclosed to law enforcement that a child was restrained with their hands behind their back. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child who is to be supervised 1:1 was permitted to leave the facility without staff supervision pursuant to an agreed upon two-hour check in agreement. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee that was no longer employeed since the beginning of May still shows active. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment. However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022. Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement. Similar discrepancies were also observed in the preliminary service plan. |
— |
| 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.
The unauthorized absence of two children in care was not reported timely. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child's service plan requires 24-hour staff supervision at all times; however, the operation was not implementing the supervision requirements as documented. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Video evidence shows a staff physically grabbing a child, picking them up, and throwing them to the ground. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
It was determined staff showed as active status since 03/30/25, however this staff was never employed by the operation |
— |
| 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.
Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Evidence shows staff was seen restraining a child without an immediate danger to self or others. |
— |
| 3 | — |
748.709(c) - Name of each designated person must be documented on the face sheet of the child's record
Resident face sheet indicates a terminated employee is the normalcy designee. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
An admission assessment was observed to only have the resident's name and date. |
— |
| 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
The medication storage cabinet was observed unlocked during the investigation inspection. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
On the video evidence provided during the investigation, staff was heard and seen yelling and cursing at a child in care. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
During the course of the investigation, the operation provided evidence that a staff was terminated; however, the operation did not inactivate the employee's background check. |
— |
| 4 | — |
748.2463(2) - Emergency Behavior Intervention-Never used as retribution or retaliation
Video footage shows the child breaking a staff's car window, and staff was seen picking the child up and slamming them to the ground. |
— |
| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
A staff member disclosed to law enforcement that a child was restrained with their hands behind their back. |
— |
| 4 | — |
748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
All allegations related to the incident were not reported to Statewide Intake. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection. The operation must address and correct all identified code violations to achieve compliance. |
— |
| 4 | — |
748.2463(2) - Emergency Behavior Intervention-Never used as retribution or retaliation
Video footage shows the child breaking a staff's car window, and staff was seen picking the child up and slamming them to the ground. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
On the video evidence provided during the investigation, staff was heard and seen yelling and cursing at a child in care. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Evidence shows staff was seen restraining a child without an immediate danger to self or others. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
It was determined staff showed as active status since 03/30/25, however this staff was never employed by the operation |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
During the course of the investigation, the operation provided evidence that a staff was terminated; however, the operation did not inactivate the employee's background check. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
An admission assessment was observed to only have the resident's name and date. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Video evidence shows a staff physically grabbing a child, picking them up, and throwing them to the ground. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection. The operation must address and correct all identified code violations to achieve compliance. |
— |
| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
A staff member disclosed to law enforcement that a child was restrained with their hands behind their back. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child who is to be supervised 1:1 was permitted to leave the facility without staff supervision pursuant to an agreed upon two-hour check in agreement. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee that was no longer employeed since the beginning of May still shows active. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment. However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022. Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement. Similar discrepancies were also observed in the preliminary service plan. |
— |
| 3 | — |
748.709(c) - Name of each designated person must be documented on the face sheet of the child's record
Resident face sheet indicates a terminated employee is the normalcy designee. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child's service plan requires 24-hour staff supervision at all times; however, the operation was not implementing the supervision requirements as documented. |
— |
| 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.
The unauthorized absence of two children in care was not reported timely. |
— |
| 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
The medication storage cabinet was observed unlocked during the investigation inspection. |
— |
| 4 | — |
748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
All allegations related to the incident were not reported to Statewide Intake. |
— |
| 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.
Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence. |
— |
| 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.
The unauthorized absence of two children in care was not reported timely. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Documents provided, such as serious incident and restraint report did not include all required components and information was observed to be missing or not documented. |
— |
| 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
The medication storage cabinet was observed unlocked during the investigation inspection. |
— |
| 3 | — |
748.303(e)(1)(A) - Serious Incident-Report to Licensing no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary
The operation did not report unsanitary conditions to the hotline. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Discrepancies were observed in the admission assessment that was evaluated. The front page of the admission assessment is dated 04/29/2025 as the date of the assessment. However, the second page states that the date of the assessment is 11/29/2022 and the expected or actual placement date is 11/29/2022. Additionally, the documentation, on page 7, references a different operation will be meeting the needs of the child instead of the current placement. Similar discrepancies were also observed in the preliminary service plan. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Video evidence shows a staff physically grabbing a child, picking them up, and throwing them to the ground. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child's service plan requires 24-hour staff supervision at all times; however, the operation was not implementing the supervision requirements as documented. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
During the walkthrough, it was observed that the ceiling in the downstairs restroom, had a black spotty substance which poses as unsanitary for the children in care. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
An admission assessment was observed to only have the resident's name and date. |
— |
| 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.
Two legal guardians of the children in care were not notified timely about the unauthorized leave of absence. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection. The operation must address and correct all identified code violations to achieve compliance. |
— |
| 3 | — |
748.709(c) - Name of each designated person must be documented on the face sheet of the child's record
Resident face sheet indicates a terminated employee is the normalcy designee. |
— |
| 4 | — |
748.2463(2) - Emergency Behavior Intervention-Never used as retribution or retaliation
Video footage shows the child breaking a staff's car window, and staff was seen picking the child up and slamming them to the ground. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During inspection inspector was notified the treatment director had recently left the operation. This time the operation does not have a treatment director. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
On the video evidence provided during the investigation, staff was heard and seen yelling and cursing at a child in care. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The operation provided inaccurate information about different incidents involving the children, as well as inaccurate documentation about restraints. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
During the course of the investigation, the operation provided evidence that a staff was terminated; however, the operation did not inactivate the employee's background check. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
The child records reviewed during inspection did not include the child orientation. The operation could not provide the child orientation. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Evidence shows staff was seen restraining a child without an immediate danger to self or others. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents. |
— |
82 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.