Capacity 16. 6-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.363(3) - Personnel records-Include current job description
1 of 9 staff records was observed to be missing a job description. |
— |
| 4 | — |
748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health
One child annual well-child check up record instructions included a follow up visit to be conducted in two weeks for a diagnoses of an infection. The child?s follow-up visit wasn?t conducted. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on 9/15/2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on 5/22/2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium weighted citation in a pattern/trend category on 5/22/2025. Specifically, the operation was cited for 748.1101(b)(3)(F). The operation met compliance on 6/4/2025. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $ 150. |
— |
| 3 | — |
748.563(c) - Professional level service provider-must meet specific educational and professional qualifications
A review of the PLSP's record reveals the PLSP does not meet the professional requirements for the position, only meets the education requirements. The PLSP does not meet the requirement of having 1 year full time experience in residential child care operation. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
4 of 4 volunteers records was observed to be missing the TB screening/results. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on March 7, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or
Four of four child records do not include whether or not a child has a chronic illness. Including a child that has asthma. |
— |
| 4 | — |
748.2463(2) - Emergency Behavior Intervention-Never used as retribution or retaliation
A child in care was placed in a restraint due to staff retaliation. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on 8/26/2022 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation. |
— |
| 1 | — |
748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value
The food menu did not have any food substitutions listed on the menu. |
— |
| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
2016 Ford Transit 350 used to transport children in care indicated needing an oil change. Oil change was conducted/completed during inspection at the operation. |
Yes |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
One staff training records reviewed was inaccurate. A new staff member?s training records showed multiple online and in person trainings completed that exceeded the maximum amount of hours the employee worked. One of the training records reviewed date of training was incorrect. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on March 14, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
Four of four child's records do not address the child's specific needs for supervision. |
— |
| 2 | — |
748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs
Four of four reviewed 72 hour plans do not address the following information: b) In addition, for a child receiving treatment services the preliminary service plan must include: (2) A description of the child?s immediate educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child (3) A description of how you will meet the child?s needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child (4) The identification of any issues or concerns the child may have that could escalate a child?s behavior. Identification of a child?s issues or concerns must serve to avoid the use of unnecessary emergency behavior interventions with the child. Child concerns may include issues with food, eye contact, physical touch, personal property, or certain topics |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
During an investigation, several children in care indicated they had been hit on the hand by a staff for trying to change the radio or turn the volume up. Other children in care witnesses this occurring. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
Thermometers were not observed in the two refrigerators of the kitchen or three freezers. Maintenance staff corrected by placement of thermometers in the two refrigerators and three freezers. |
Yes |
| 3 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation continues to be without a qualified full time Licensed Child Care Administrator. The operation's board continues efforts in the search for an Administrator. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
During an investigation, several children in care indicated that staff were loud with them or had yelled at them. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
Room 5 had mildew on the closet ceiling. |
Yes |
| 2 | — |
748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
A child's record did not document when their dental appointment was scheduled or if the child has had a dental examination within the past year. |
— |
| 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 an inspection, an employee no longer with the operation remained active on the people list. |
Yes |
| 4 | — |
748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
A staff EBI SAMA training certificate was expired. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
Based on information gathered during an evaluation of the operation's records, it was found a child's record contained inaccurate documentation as related to a document in the child's record. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
The operation's fire inspection has expired as of 03/02/2022. |
— |
| 5 | — |
745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
1 of 9 employee files did not contain the pre-employment drug testing results. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
A child fell on the return from school on 11/19/21, injuring her arm and leg, requiring medical treatment (received same day), and follow ups. The operation did not report the serious incident until 11/21/21. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on September 5, 2023, it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During the inspection, a medication error was discovered. In the child's file reviewed, a medication error occurred in which the remaining medication count was 52. However, the medication log reflected 53. |
— |
| 2 | — |
748.1217(c)(7) - Admission Assessment-Prior to initial service plan, add child's history of other placements (admission and discharge dates, reasons for placement)
The following information was not added to four of four reviewed records, prior to the ISP being conducted: (3) The child?s birth and neonatal history (4) The child?s developmental history (5) The child?s mental health and substance abuse history (6) The child?s school history, including the names of previous schools attended and the dates the schools were attended, grades earned, and special achievements (7) The child?s history of any other placements outside the child?s home, including the admission and discharge dates and reasons for placement (8) The child?s criminal history (9) The child?s skills and special interests |
— |
| 3 | — |
748.3273(2) - First Aid Kits-Each one must contain adhesive tape
First Aid Kit was observed without adhesive tape and thermometer. Items were placed in the First Aid Kit prior to exiting the inspection. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the investigation, it was discovered that a caregiver fell asleep on an evening shift. |
— |
| 4 | — |
748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible
A child in care had head lice, and the operation staff failed to provide continuous care in order to ensure the head lice was no longer present. |
— |
| 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.
A child's unauthorized absence was not reported to licensing within 6 hours. |
— |
| 5 | — |
748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development
During a walk thru multiple foods were expired in the pantry area. |
— |
| 4 | — |
748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
A caregiver's Emergency Behavior Intervention training was not renewed timely. |
— |
| 4 | — |
748.3441(p) - Food Preparation-Must maintain hot food at 140 degrees Fahrenheit or above
The operation had 11 prepared individual food plates stored on the countertop covered with plastic wrap at 2:43PM with the intention to reheat and serve the food for dinner at 5PM. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
Med logs were reviewed during a heightened monitoring contracts inspection on 11/1/2023 for youth D.M. During the review of the medication log and medication, RCM observed the medication count for AM Risperidone did not correspond with medication log. According to the medication log there were 2 tablets for Risperidone remaining on the AM log; however, there was only one pill remaining. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
Four of four records do not document an assessment of the child's information to evaluate the appropriateness of placement. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A staff member at the operation was not providing adequate supervision to children in care due to the staff sleeping. |
— |
| 3 | — |
748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
During a monitoring inspection, the operation was unaware of an evaluation that addressed the unauthorized absences. |
— |
| 4 | — |
748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
A child in care was restrained because she threw a ball that hit an employee on the leg. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on 2/28/2023 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High weighted citations. |
— |
| 3 | — |
748.1221(a) - Admission Assessment-Must make reasonable efforts to obtain all required information
Four of four reviewed records did not document the operation's efforts to obtain information missing in order to complete the child's record. |
— |
| 1 | — |
748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided
No written plan for indoor and outdoor recreation was available for review during inspection. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The medication was prescribed on 09-06-22 and not administered/received by the operation until 09-16-22. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on September 9, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32. |
— |
| 3 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation does not have a qualified full time Licensed Child Care Administrator. |
— |
| 1 | — |
748.1703(c) - Menus-must date menus and keep copies for 90 days
The food menu did not have the month or the dates on the menu. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During the inspection, it was found that the Development Public Relation Coordinator did not have a background check submitted or cleared prior to being allowed to be present at the operation. In order to assure timely completion of background checks, it is recommended that the operation submit background checks prior to allowing employees to be present at the facility. |
Yes |
| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
During the course of interviews with children in the operation, it was found that that one staff member made comments that were demeaning and negative towards their body and weight. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
A child's record contains inconsistent information regarding the child's admission date on the ISP and 72Hr. Another child's record has conflicting information regarding the recreational and normalcy activities. |
— |
| 3 | — |
748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them
RCM completed an HM visit at Girls Haven on 05/14/2025 RCM observed a youth?s hair to remain in dry, flaky, brittle, and unmanaged. Her hair was observed to be dry, flaky brittle and unmanaged during the visit on 04/30/2025, at which the administrator stated she would ensure the youth receive proper hair treatment. During the visit on 04/30/2025, RCM spoke with the youth regarding her hair treatment. The youth stated she previously had braids but took them down after a few weeks because her scalp was itching and flaking. She was informed by staff she could not get braids again because she took them down to soon. On 05/14/2025 RCM spoke with the same youth regarding her hair care. Youth reported she blow dries her hair in the morning. When asked why she blow dries her hair when its already dry, youth stated she wants it to be strait. RCM advised she needs to moisturize her hair daily to prevent it from breaking. Youth stated her sister (also placed at the facility) was going to braid her hair. It?s important to note other youth (of African American decent) hair was also observed to be dry and in need of treatment. |
— |
| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The fire inspection conducted identified areas of concern that needed correction. |
— |
| 4 | — |
748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint
Four of four child records did not address the known contraindications to the use of restraints. |
— |
| 4 | — |
748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.
Four of four reviewed child files were missing information regarding: (3) A description of the child?s behavior, including appropriate and maladaptive behavior, and any high-risk behavior (4) Any history of physical, sexual, or emotional abuse or neglect (5) Any history of trauma (6) Current medical and dental status, including the available results of any medical and dental examinations (7) Current substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment (9) The child?s current educational level and any school problems (15) The child?s understanding of the placement (16) A determination of whether and how you can meet the needs of the child |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
6 of 9 employee records reviewed contained employment affidavits that were not notarized. 1 of 9 employees records reviewed did not contain an employment affidavit. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
The operations' emergency relocation map does not show shelter in place designation. The administrator reprinted the relocation map wth the shelter in place location. |
Yes |
| 4 | — |
748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
During an inspection, a personnel record did not contain evidence of two reference checks completed. |
— |
| 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 an inspection, the service plan for a child was not signed by the case manager. |
Yes |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
During an investigation, several children in care indicated that staff were loud with them or had yelled at them. |
— |
| 1 | — |
748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value
The food menu did not have any food substitutions listed on the menu. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
Med logs were reviewed during a heightened monitoring contracts inspection on 11/1/2023 for youth D.M. During the review of the medication log and medication, RCM observed the medication count for AM Risperidone did not correspond with medication log. According to the medication log there were 2 tablets for Risperidone remaining on the AM log; however, there was only one pill remaining. |
— |
| 4 | — |
748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
During an inspection, a personnel record did not contain evidence of two reference checks completed. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
A child fell on the return from school on 11/19/21, injuring her arm and leg, requiring medical treatment (received same day), and follow ups. The operation did not report the serious incident until 11/21/21. |
— |
| 4 | — |
748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.
Four of four reviewed child files were missing information regarding: (3) A description of the child?s behavior, including appropriate and maladaptive behavior, and any high-risk behavior (4) Any history of physical, sexual, or emotional abuse or neglect (5) Any history of trauma (6) Current medical and dental status, including the available results of any medical and dental examinations (7) Current substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment (9) The child?s current educational level and any school problems (15) The child?s understanding of the placement (16) A determination of whether and how you can meet the needs of the child |
— |
| 4 | — |
748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
A child in care was restrained because she threw a ball that hit an employee on the leg. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
One staff training records reviewed was inaccurate. A new staff member?s training records showed multiple online and in person trainings completed that exceeded the maximum amount of hours the employee worked. One of the training records reviewed date of training was incorrect. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The medication was prescribed on 09-06-22 and not administered/received by the operation until 09-16-22. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or
Four of four child records do not include whether or not a child has a chronic illness. Including a child that has asthma. |
— |
| 3 | — |
748.363(3) - Personnel records-Include current job description
1 of 9 staff records was observed to be missing a job description. |
— |
| 3 | — |
748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
During a monitoring inspection, the operation was unaware of an evaluation that addressed the unauthorized absences. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on 9/15/2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on 5/22/2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium weighted citation in a pattern/trend category on 5/22/2025. Specifically, the operation was cited for 748.1101(b)(3)(F). The operation met compliance on 6/4/2025. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $ 150. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
Four of four child's records do not address the child's specific needs for supervision. |
— |
| 3 | — |
748.3273(2) - First Aid Kits-Each one must contain adhesive tape
First Aid Kit was observed without adhesive tape and thermometer. Items were placed in the First Aid Kit prior to exiting the inspection. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on March 14, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32. |
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| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
2016 Ford Transit 350 used to transport children in care indicated needing an oil change. Oil change was conducted/completed during inspection at the operation. |
Yes |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
Room 5 had mildew on the closet ceiling. |
Yes |
| 4 | — |
748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible
A child in care had head lice, and the operation staff failed to provide continuous care in order to ensure the head lice was no longer present. |
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| 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.
A child's unauthorized absence was not reported to licensing within 6 hours. |
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| 3 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation continues to be without a qualified full time Licensed Child Care Administrator. The operation's board continues efforts in the search for an Administrator. |
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| 1 | — |
748.1703(c) - Menus-must date menus and keep copies for 90 days
The food menu did not have the month or the dates on the menu. |
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| 2 | — |
748.1217(c)(7) - Admission Assessment-Prior to initial service plan, add child's history of other placements (admission and discharge dates, reasons for placement)
The following information was not added to four of four reviewed records, prior to the ISP being conducted: (3) The child?s birth and neonatal history (4) The child?s developmental history (5) The child?s mental health and substance abuse history (6) The child?s school history, including the names of previous schools attended and the dates the schools were attended, grades earned, and special achievements (7) The child?s history of any other placements outside the child?s home, including the admission and discharge dates and reasons for placement (8) The child?s criminal history (9) The child?s skills and special interests |
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| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
The operations' emergency relocation map does not show shelter in place designation. The administrator reprinted the relocation map wth the shelter in place location. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on 8/26/2022 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation. |
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| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
During the course of interviews with children in the operation, it was found that that one staff member made comments that were demeaning and negative towards their body and weight. |
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| 4 | — |
748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report
The fire inspection conducted identified areas of concern that needed correction. |
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| 4 | — |
748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
A caregiver's Emergency Behavior Intervention training was not renewed timely. |
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| 5 | — |
745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
1 of 9 employee files did not contain the pre-employment drug testing results. |
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| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
Four of four records do not document an assessment of the child's information to evaluate the appropriateness of placement. |
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| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the investigation, it was discovered that a caregiver fell asleep on an evening shift. |
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| 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 an inspection, the service plan for a child was not signed by the case manager. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A staff member at the operation was not providing adequate supervision to children in care due to the staff sleeping. |
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| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on September 9, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32. |
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| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During the inspection, it was found that the Development Public Relation Coordinator did not have a background check submitted or cleared prior to being allowed to be present at the operation. In order to assure timely completion of background checks, it is recommended that the operation submit background checks prior to allowing employees to be present at the facility. |
Yes |
| 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 an inspection, an employee no longer with the operation remained active on the people list. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on September 5, 2023, it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
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| 3 | — |
748.1221(a) - Admission Assessment-Must make reasonable efforts to obtain all required information
Four of four reviewed records did not document the operation's efforts to obtain information missing in order to complete the child's record. |
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| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During the inspection, a medication error was discovered. In the child's file reviewed, a medication error occurred in which the remaining medication count was 52. However, the medication log reflected 53. |
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| 3 | — |
748.563(c) - Professional level service provider-must meet specific educational and professional qualifications
A review of the PLSP's record reveals the PLSP does not meet the professional requirements for the position, only meets the education requirements. The PLSP does not meet the requirement of having 1 year full time experience in residential child care operation. |
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304 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.