Capacity 68. 6-18
| Severity | Date | Standard / narrative | Corrected |
|---|
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
The one first aid kit at the operation was missing a thermometer - as required by minimum standards. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child in care was unaccounted for, for approximately 3 hours after school. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the investigation inspection, there was a bowl of food (corn) uncovered and stored in the refrigerator. |
— |
| 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 investigation, I observed the medication logs for one child's medication failed to document an administration of this medication on 12/21/24. |
— |
| 2 | — |
748.3273(9) - First Aid Kits-Each one must contain tweezers
During the monitoring inspection, the first aid kit was missing tweezers. |
— |
| 3 | — |
748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required
The operation is equipped with an electric smoke detection system, and the operation was not able to produce documentation of annual testing of the system by an approved party. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During a physical site inspection, one gallon of milk in the cottage refrigerator expired on 5/18/2026. A remaining loaf of bread stored in the bread cabinet had mold. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
There were several medication sheets for two boys that did not state the reason the medications were prescribed. |
— |
| 1 | — |
748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
During the investigation, I observed the service plan for one child did not include his signature or documentation of refusal. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
During the monitoring inspection, one child's medication records was missing the reason medication was prescribed. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
The kids' bathroom on the right side of the facility had mold in the shower floor and doors. There were soiled walls and baseboards around the large trash can, and the vents were covered with dust. |
— |
| 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
During a walk through of the operation one bathroom was found not to have hand towels at the sink. Staff corrected this issue at the time of the inspection. |
Yes |
| 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
Two of the children's beds (in use) had no pillowcases. |
— |
| 1 | — |
748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate. At minimum must give copy to child 14 years and older
In three of the four records reviewed, there was either no date for a copy of the service plan being provided to the children, no child's signature, or no documentation that a copy was provided to the child. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
During the monitoring inspection, there was one medication record that did not have documentation of the medication (Escitalopram 10mg) administered to the child on the evening of 4/27/2024. |
— |
| 3 | — |
748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child
During the investigation, it was learned that a post discussion with the child was not held after he was restrained. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During the unannounced after hours inspection, it was observed that a child's medication record and actual medication count did not match. The medication record reflected there were 24 doses remaining while the package only contained 23 doses. |
— |
| 4 | — |
748.685(d)(3) - Caregiver responsibility- Child participating in unsupervised activity - caregiver must provide/arrange/ confirm transportation to & from activity
Caregivers at the operation did not communicate or confirm who was going to pick a child up after school. The child was left unattended for approximately three hours. |
— |
| 3 | — |
748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations
During the ANE Investigation, it was reported the operation staff permitted a child to go into the staff office, close, and lock the door, behind him. At that time, the child had access to child records that are stored in the staff office. |
— |
| 4 | — |
748.685(d)(4) - Supervision caregiver responsibility- Child participating in unsupervised activity - caregiver must give child way to contact him/her in an emergency
A child in care was off campus and did not have a phone number to call to be picked up. |
— |
| 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 inspection, I observed pillow cases and sheets missing from a number of the children's beds. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
There were 4 tomatoes with mold in the refrigerator and several packets of snack sandwiches covered in mold. Also, a large bag of shredded cheese was completely opened in the same drawer. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the monitoring inspection, a package of spinash that was found rotten, expired, and almost liquified in the refrigerator. |
Yes |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
During the monitoring inspection, the operation did not provide documents, when requested. Copies of the admissions assessments were provided after the conclusion of the inspection, but discharge summaries were never produced. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
A young man with a history of sexual abuse and a pre-occupation with pornography did not receive adequate supervision. This resulted in sexually inappropriate behaviors and solicitation of younger kids. |
— |
| 5 | — |
748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being
During the investigation, it was learned that no one was monitoring the child while he was being restrained. |
— |
| 3 | — |
748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment
The residents and staff witnessed a caregiver threatening placements and inappropriate discipline at the operation. |
— |
| 3 | — |
748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
Upon reviewing fire inspections, it is noticed that their most recent fire drill was done outside of the 6 months on 4/2/2023. This was corrected at the inspection by the operation conducting a fire drill. |
Yes |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed no thermometer in the refrigerator. The operation replaced the thermometer during the inspection. |
Yes |
| 3 | — |
748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
The facility did not have any record of severe weather drills. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During the investigation inspection, medication records were reviewed, and it was observed that one child's medication record was inaccurate. The record indicated the medication had 26 doses remaining, while the package only contained 25 doses. It was also observed that the balance on the medication record was wrong and there was not a deduction after each dose provided. This was previously cited at the monitoring inspection completed in May of this year. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
There was nothing written on a child's medication record for "reason the medication was prescribed". |
— |
| 3 | — |
748.1269(a) - Emergency Admission-Complete all requirements for an admission assessment within 40 days of admission
An Emergency Admission Assessment was not completed for the victim child in this case. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection, I observed the curtains in one bedroom to be suspended in such a way that the curtains did not adequately cover the window to provide requisite privacy or sufficiently block light for rest. |
— |
| 1 | — |
748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves
There were no menus in either house on campus. The operation has not been utilizing menus due to grocery changes every week. |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The investigation revealed that the operation did not inform the permanency specialist/conservator of a child in care's fractured hand. The permanency specialist/conservator remained unaware until the inspector brought it to her attention. |
— |
| 4 | — |
748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times
One of the facility vans had a protruding wire sticking out of the second seat and a sliding door that came off the hinges when the door was opened. This was corrected at the initial inspection, but residents were transported in this vehicle for several weeks before the issues were fixed. |
Yes |
| 3 | — |
748.3271 - First Aid Kits-All separate living areas & buildings must have first-aid kit available; first-aid kit must be available for field trips
There was one first aid kit in the house, but none in the vehicles to transport the boys. There should always be one available for the vehicle that is taking the kids on an outing. There should be a minimum of two at the Valley View Cottage. |
— |
| 3 | — |
748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean
During the inspection, I observed a sink a cottage bathroom with a broken hot water knob preventing its use. The operation repaired the knob while I was there for the inspection. |
Yes |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
During the investigation, I observed one child's medication log contained an entry for which no time of administration was recorded. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the inspection, I observed the operation last administered a prescription nasal spray on 9/27/24 prior to the child's visit. The medication was not administered again following that date as it did not return to the operation from the visit. As of the date of the inspection, the operation was not in posession of this prescription medication and the child has not received an administration since 9/27/24 |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
A child was seriously injured on 9/22/24, and the parent was not notified until 9/23/24, a day after the child was verified safe. |
— |
| 3 | — |
748.1337(b)(1)(D) - Initial Service Plan-Include specific goals and strategies to meet the child's needs, including instructions to caregivers
During the investigation, I observed six child service plans lacked specific goals in multiple areas. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, I observed a hole in the surround of a shower stall, and the operation did not show a maintenance request on file for the damage. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
After a series of events including attempted property destruction, defiance, bullying, and fighting, 3 out of 4 residents reported they did not feel safe at the operation due to a lack of protection from physical altercations and/or bullying. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the investigation, I observed two staff failed to take Trauma Informed Care training in 2024. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the investigation, it was found that the staff member on duty did not intervene when two children began physically fighting. This resulted in a child in care having to intervene in order to stop the altercation. The staff member lacked prudent judgement in not trying to stop the altercation between the two children. |
— |
| 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 this investigation, evidence indicates that a staff failed to properly supervise children in care, resulting in a resident having inappropriate contact with a minor online and several residents being able to congregate, contact this same minor, and call the police without the staff's awareness. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the monitoring inspection, there was rotten fruit observed in the refrigerator. |
Yes |
| 3 | — |
748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
Upon reviewing documents, it is noticed that the operation did not have documentation or had conducted a severe weather drill. This was also corrected at the inspection by having a severe weather drill conducted by the operation. |
Yes |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A preliminary service plan was not provided for the victim child in this case. |
— |
| 1 | — |
748.1337(b)(1)(A)(vii) - Initial Service Plan-Include therapeutic needs, including plans for evals, follow-up treatment, testing and use of psychotropic medications
During the investigation, I observed a child's service plan lacking the results of the most recent Psychological Evaluation or attempts to schedule a new one. |
— |
| 1 | — |
748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents
During the investigation, I observed a child's service plan failed to record when the plan was provided to the child's parent entity. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the inspection, I observed a medication log for a child included documentation of one medication administration on 9/30/24 that staff confirmed did not occur as the medication did not return with the child from his last visit and the operation was not in posession of the medication at the time of this inspection. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During a heightened monitoring visit to the operation on 08/14/2025, some donuts, with a best if used by date of 08/04/25, located on the counter in the kitchen were observed to have mold on them. |
— |
| 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
During the walk through of the operation it was found that there were no towels at the sinks in the one of the bathrooms. |
Yes |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Two beds did not have protective convers separating the mattress and the sheet. There was also one pillow case missing. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
The medication count for one of the residents did not match the medication documentation log |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
An employee at the operation was using profanity towards the residents and in the presence of direct care staff. |
— |
| 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
During the investigation inspection, two of the three bathrooms had empty paper towel dispensers and no personal towels or hand dryers for use. This was previously citated at the last inspection completed earlier this month. |
— |
| 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
A caregiver argued with children in care, and then she commented "at least I have a home to go home to" - which was demeaning to the boys in the facility. |
— |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
During the monitoring inspection, the operation was not able to provide all documents when requested such as discharge summaries for two children. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the walk through of the inspection, it is noticed that the pantry door had a hole and the ledge of it was coming off. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
There were over 5 places found where a staff failed to sign when medicatoins were given. The timeframe ranged from late 2021 to May of 2022. |
— |
| 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 walk through of the operation, it is noticed that 2 of the boys bedrooms did not have pillow cases on the pillow. This was corrected at the inspection by one pillow being removed from the room and a pillow case being added to the other pillow. |
Yes |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
The investigation revealed that a child in care suffered an injury which was not promptly addressed. The child, having injured his hand, was seen by a doctor who recommended an X-ray. However, the X-ray was not performed until two weeks following this recommendation. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During a walk-through of the operation, it was observed that conditions of a cabin were not clean. The boy's rooms were observed to be cluttered, the bathroom toilet dispenser was broken off, dirty dishes were observed in the kitchen sink and a liquid was observed on one of the bedroom floors. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the investigation, I observed the service plans for three children did not include available CAN's results and accurate recommendations. |
— |
| 2 | — |
748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times
During the walk through of the operation, it is noticed that 2 of the restrooms did not have toilet paper in the bathrooms. This was corrected during the inspection by rolls of toilet paper being added to those bathrooms. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Roughhousing between two residents escalated. One resident placed the other in a headlock and transitioned to placing hands around the neck and choking. The caregiver delayed to de-escalate and intervene. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
One child's medication log did not include the reason the medication was prescribed. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child in care reported seeing a caregiver sleeping while on night duty. The child called out to the caregiver while getting a drink of water and initially received no response until being woken. One caregiver reported observing the same caregiver sleeping on duty when coming on shift. This occurred on two separate occasions. One caregiver also reported observing a separate caregiver sleeping in the office. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the monitoring inspection, a window located next to the front door was observed to have a crack. There was also a toilet in the home that was observed to be dirty and needing to be cleaned. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
During the investigation, it was learned that the caregiver for the children did not try to intervene in anyway when the altercation started including the verbal altercation. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Four beds in use had no mattress protectors. |
— |
| 5 | — |
748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint
During the investigation, it was found that a child in care restrained another child in care. The child in care who conducted the restraint does not have the necessary training in restraints. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
During the monitoring inspection, a bottle of Pine-Sol was observed to be in the common area and accessible to a child in care. |
Yes |
| 2 | — |
748.1385(2) - Service Plan Review-Must identify any new needs and strategies or techniques to meet these needs, including instructions to employees
In reviewing the documentation, I observed that the resident's service plan did discuss or assess documented behaviors that resulted in increased supervision levels as documented in the operation's corrective actions to a previous investigation. |
— |
| 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 04/09/2026 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; and ? Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
The operation failed to comply with the safety plan implemented during the ANE investigation. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the inspection, I observed a medication log for a child included documentation of one medication administration on 9/30/24 that staff confirmed did not occur as the medication did not return with the child from his last visit and the operation was not in posession of the medication at the time of this inspection. |
— |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
During the monitoring inspection, the operation was not able to provide all documents when requested such as discharge summaries for two children. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the monitoring inspection, a window located next to the front door was observed to have a crack. There was also a toilet in the home that was observed to be dirty and needing to be cleaned. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A preliminary service plan was not provided for the victim child in this case. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
The investigation revealed that a child in care suffered an injury which was not promptly addressed. The child, having injured his hand, was seen by a doctor who recommended an X-ray. However, the X-ray was not performed until two weeks following this recommendation. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
There was nothing written on a child's medication record for "reason the medication was prescribed". |
— |
| 3 | — |
748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
The facility did not have any record of severe weather drills. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
A young man with a history of sexual abuse and a pre-occupation with pornography did not receive adequate supervision. This resulted in sexually inappropriate behaviors and solicitation of younger kids. |
— |
| 1 | — |
748.1337(b)(1)(A)(vii) - Initial Service Plan-Include therapeutic needs, including plans for evals, follow-up treatment, testing and use of psychotropic medications
During the investigation, I observed a child's service plan lacking the results of the most recent Psychological Evaluation or attempts to schedule a new one. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Two beds did not have protective convers separating the mattress and the sheet. There was also one pillow case missing. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
After a series of events including attempted property destruction, defiance, bullying, and fighting, 3 out of 4 residents reported they did not feel safe at the operation due to a lack of protection from physical altercations and/or bullying. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the investigation, I observed the service plans for three children did not include available CAN's results and accurate recommendations. |
— |
| 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 investigation, I observed the medication logs for one child's medication failed to document an administration of this medication on 12/21/24. |
— |
| 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
During the walk through of the operation it was found that there were no towels at the sinks in the one of the bathrooms. |
Yes |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The investigation revealed that the operation did not inform the permanency specialist/conservator of a child in care's fractured hand. The permanency specialist/conservator remained unaware until the inspector brought it to her attention. |
— |
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
The one first aid kit at the operation was missing a thermometer - as required by minimum standards. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
An employee at the operation was using profanity towards the residents and in the presence of direct care staff. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Roughhousing between two residents escalated. One resident placed the other in a headlock and transitioned to placing hands around the neck and choking. The caregiver delayed to de-escalate and intervene. |
— |
| 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 04/09/2026 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; and ? Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation. |
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748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
One child's medication log did not include the reason the medication was prescribed. |
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296 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.