Capacity 13. 10-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
It was observed during the walkthrough that there was no hand washing soap in side 3 restroom. |
Yes |
| 5 | — |
748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance
The van has only 8 operable seat belts out of a total of 14 seats. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs. |
— |
| 2 | — |
748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge
During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24 |
— |
| 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 of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that a child in care did not have a matress protector on their bed. |
— |
| 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 January 31, 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. As you know, the heightened monitoring plans 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 plans, 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 plans. |
— |
| 4 | — |
748.863(a)(3) - Pre-Service Training-Caregiver for child-care or programmatic services only must have 8 hours EBI training, 4 pre-service & rest within 90 days
Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days. |
— |
| 2 | — |
748.681(1)(B) - Caregiver qualifications-Must be at least 21 yrs old if all children in group are 13 yrs old or older
According to the investigation, staff member was age 20 caring for children 13 years and older. |
— |
| 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 review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection. |
— |
| 5 | — |
748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute
According to the investigation, a child was placed in a supine position for more than 1 minute. |
— |
| 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 of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles. |
— |
| 3 | — |
748.453(a)(5) - Unauthorized Absence - Annual summary log must include the intake report number, if report was made to CCR or DFPS
The log provided did not include the intake report number, age, and gender of the child's unauthorized absence. |
— |
| 4 | — |
748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.
It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22 |
— |
| 3 | — |
748.861(b)(1) - Pre-Service Training - Caregiver may not be solely responsible for a group of children
According to the investigation, a new staff was left alone with children in care |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care sustained injury under his left eyes during physical altercation with another resident. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission
The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff used profanity while supervising kids at the facility. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files. |
Yes |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Children gained access to a bottle of hand sanitizer and were able to ingest it. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission
Upon reviewing the annual summary log, it was determined that certain required components were missing in accordance with Minimum Standards including: -The gender of the adolescent. -The name of the caregiver responsible for the child at the time of absence. -The intake report number. -Whether law enforcement was contacted including the name of the law enforcement agency and the number of the police report. |
— |
| 3 | — |
748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress
During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24 while the date of admission in the childrens list says 5-10-24. |
Yes |
| 4 | — |
748.535(2) - Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on July 29, 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. As you know, the heightened monitoring plans 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 plans, 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: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - 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. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
One open energy drink was found inside the fridge during the walkthrough of the kitchen |
Yes |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
The child medication log reviewed was observed prefilled of the amount given approximately 7 hours before evening administration. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Two children in care disclosed a staff member threatened residents. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Multiple children in care stated that staff cuss at them. |
— |
| 5 | — |
748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides
The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24. |
Yes |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL. |
— |
| 3 | — |
748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy
Side 3 restroom was observed without a shower curtain during the walkthrough |
Yes |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician |
— |
| 2 | — |
748.363(13) - Personnel records - Include any documentation of the person's performance with the operation.
During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection. |
Yes |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern. |
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 previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation did not provide requested documents in a timely manner after multiple attempts. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection. |
Yes |
| 3 | — |
748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
A child was restrained but the incident was not appropriately documented on the EBI Report. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23. |
— |
| 4 | — |
748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director. |
Yes |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22 |
— |
| 4 | — |
748.3441(n) - Food Preparation-Food must be protected from contamination
During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member entered a child's room during sleeping hours and engaged in physical contact. Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection. |
Yes |
| 4 | — |
748.3441(n) - Food Preparation-Food must be protected from contamination
During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed. |
— |
| 2 | — |
748.363(13) - Personnel records - Include any documentation of the person's performance with the operation.
During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker. |
— |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern. |
Yes |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director. |
Yes |
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
It was observed during the walkthrough that there was no hand washing soap in side 3 restroom. |
Yes |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician |
— |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22 |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
One open energy drink was found inside the fridge during the walkthrough of the kitchen |
Yes |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request. |
— |
| 2 | — |
748.681(1)(B) - Caregiver qualifications-Must be at least 21 yrs old if all children in group are 13 yrs old or older
According to the investigation, staff member was age 20 caring for children 13 years and older. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Two children in care disclosed a staff member threatened residents. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate. |
— |
| 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 of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection. |
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 previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation did not provide requested documents in a timely manner after multiple attempts. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall. |
— |
| 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 of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Multiple children in care stated that staff cuss at them. |
— |
| 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 review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week. |
— |
| 4 | — |
748.863(a)(3) - Pre-Service Training-Caregiver for child-care or programmatic services only must have 8 hours EBI training, 4 pre-service & rest within 90 days
Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days. |
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| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff used profanity while supervising kids at the facility. |
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| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that a child in care did not have a matress protector on their bed. |
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| 4 | — |
748.535(2) - Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on July 29, 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. As you know, the heightened monitoring plans 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 plans, 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: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - 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. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
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316 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.