Texas › Tyler › Children's Village and Family Service Agency, Inc.

Children's Village and Family Service Agency, Inc.

Child care center · 3659 FM 724, Tyler, TX 75704-5645 · License 154645

0Compliance score
Poor

Capacity 32. 0-18

Violation history (240)

Severity	Date	Standard / narrative	Corrected
1	—	748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents None of the child records showed any documentation that the CPS caseworker was notified at least two weeks in advance of the child's plan meeting.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 During the inspection, I observed four of four employee records reviewed lacked Affidavit Form 2912.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the inspection, I observed the professional test for the smoke detectors was six days overdue.	—
2	—	748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting On two of the child plans, the implementation date was marked to be 10 days before signatures, and one plan showed an implementation date that was 28 days before the parties signed the plan.	—
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. Three of the four employee files read did not contain certificates for Medication of Administration.	—
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs During the inspection, we observed three of three service plan updates lacked evaluations of effective strategies and goals for the children. The service plans also lacked evaluation of Normalcy services.	—
2	—	748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves During the inspection, I observed one of two first aid kits reviewed lacked a pair of waterproof gloves.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication During the after hours walkthrough, I observed three of four prescription medication logs lacked the reason the medication was prescribed.	—
4	—	748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material During the inspection, we observed the loose fill under the playground equipment was between 3.5-5 inches in depth.	—
1	—	748.1385(7) - Service Plan Review-Must update the estimated length of stay and discharge plans, if changed During the inspection, we observed three of three service plan updates reviewed lacked updates to the estimated length of stay. The children have exceeded the length of stay estimated in the admission assessment.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container One of the First Aid Kits had numerous packets of medication, which are required to be locked.	Yes
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name During the Inspection, we observed two of three children's medication logs lacked documentation of the prescribing doctor's information on the form.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled at a foster child on more than one occasion. He also put his hand on the younger sibling's neck while guiding him to his bedroom.	—
3	—	748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes During the inspection five fire drill were reviewed. Out of the five fire drills reviewed one did not have the designated meeting area..	—
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 the refrigerator and freezer in the cottage to be lacking thermometers. The house parent replaced the thermometers while I was present.	Yes
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection During the inspection, I observed the operation has not had a fire inspection in over 1.5 years.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the monitoring inspection,the operation did not have documentation that the automatic fire alarm system in Cottage A had been tested within the previous 12 months.	—
3	—	748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care During the inspection, we observed two of two first aid kits reviewed lacked the first aid guide.	—
3	—	748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights During the inspection, we observed two of three child's rights reviewed lacked documentation of the date reviewed with the child.	—
2	—	748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results On one dental exam, the bill and pictures of teeth were in the file, but there was no explanation of what was done or who the Dentist was.	—
3	—	748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below During the monitoring inspection, it was observed that the freezer in Cottage A did not have a thermometer.	—
4	—	748.931(b)(2) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 1 hour normalcy. During the inspection, we observed two of four employee records reviewed lacked proof of annual Normalcy training.	Yes
5	—	748.2101(1) - Medication Storage-Store medication in a locked container During the inspection of Cottage A medication was found not be stored in a locked container.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, I observed several medication logs to have entries with the initials of an individual administerinig the meds but no full name or signature.	—
4	—	748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model In reviewing the medication logs for Cottage A they did not have a updated medication log for the children in care.	—
3	—	748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available Three of the four children's records showed that the initial medical exams were done 4, 3, and 2 days late.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, we observed one of the three children's med log records reviewed lacked the signatures of the administering staff.	—
2	—	748.3273(8) - First Aid Kits-Each one must contain thermometer The main vehicle for the cottage did not have a thermometer in the First Aid Kit.	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 monitoring inspection, it was observed that the refrigerator in Cottage A did not have a thermometer.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The Health and Sanitation inspection was due earlier this month. The most recent inspection was done on 8/8/2022 .	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 During the inspection, I observed four of four employee records reviewed lacked Affidavit Form 2912.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled at a foster child on more than one occasion. He also put his hand on the younger sibling's neck while guiding him to his bedroom.	—
4	—	748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model In reviewing the medication logs for Cottage A they did not have a updated medication log for the children in care.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the inspection, I observed the professional test for the smoke detectors was six days overdue.	—
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs During the inspection, we observed three of three service plan updates lacked evaluations of effective strategies and goals for the children. The service plans also lacked evaluation of Normalcy services.	—
2	—	748.3273(8) - First Aid Kits-Each one must contain thermometer The main vehicle for the cottage did not have a thermometer in the First Aid Kit.	Yes
3	—	748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below During the monitoring inspection, it was observed that the freezer in Cottage A did not have a thermometer.	—
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 the refrigerator and freezer in the cottage to be lacking thermometers. The house parent replaced the thermometers while I was present.	Yes
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, we observed one of the three children's med log records reviewed lacked the signatures of the administering staff.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name During the Inspection, we observed two of three children's medication logs lacked documentation of the prescribing doctor's information on the form.	—
4	—	748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material During the inspection, we observed the loose fill under the playground equipment was between 3.5-5 inches in depth.	—
4	—	748.931(b)(2) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 1 hour normalcy. During the inspection, we observed two of four employee records reviewed lacked proof of annual Normalcy training.	Yes
4	—	748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection During the inspection, I observed the operation has not had a fire inspection in over 1.5 years.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The Health and Sanitation inspection was due earlier this month. The most recent inspection was done on 8/8/2022 .	—
3	—	748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below During the monitoring inspection, it was observed that the refrigerator in Cottage A did not have a thermometer.	—
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. Three of the four employee files read did not contain certificates for Medication of Administration.	—
1	—	748.1385(7) - Service Plan Review-Must update the estimated length of stay and discharge plans, if changed During the inspection, we observed three of three service plan updates reviewed lacked updates to the estimated length of stay. The children have exceeded the length of stay estimated in the admission assessment.	—
3	—	748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes During the inspection five fire drill were reviewed. Out of the five fire drills reviewed one did not have the designated meeting area..	—
1	—	748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents None of the child records showed any documentation that the CPS caseworker was notified at least two weeks in advance of the child's plan meeting.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, I observed several medication logs to have entries with the initials of an individual administerinig the meds but no full name or signature.	—
3	—	748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights During the inspection, we observed two of three child's rights reviewed lacked documentation of the date reviewed with the child.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication During the after hours walkthrough, I observed three of four prescription medication logs lacked the reason the medication was prescribed.	—
3	—	748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available Three of the four children's records showed that the initial medical exams were done 4, 3, and 2 days late.	—
2	—	748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results On one dental exam, the bill and pictures of teeth were in the file, but there was no explanation of what was done or who the Dentist was.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container During the inspection of Cottage A medication was found not be stored in a locked container.	—
3	—	748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care During the inspection, we observed two of two first aid kits reviewed lacked the first aid guide.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the monitoring inspection,the operation did not have documentation that the automatic fire alarm system in Cottage A had been tested within the previous 12 months.	—
2	—	748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves During the inspection, I observed one of two first aid kits reviewed lacked a pair of waterproof gloves.	—
2	—	748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting On two of the child plans, the implementation date was marked to be 10 days before signatures, and one plan showed an implementation date that was 28 days before the parties signed the plan.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container One of the First Aid Kits had numerous packets of medication, which are required to be locked.	Yes
1	—	748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents None of the child records showed any documentation that the CPS caseworker was notified at least two weeks in advance of the child's plan meeting.	—
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs During the inspection, we observed three of three service plan updates lacked evaluations of effective strategies and goals for the children. The service plans also lacked evaluation of Normalcy services.	—
2	—	748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves During the inspection, I observed one of two first aid kits reviewed lacked a pair of waterproof gloves.	—
3	—	748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes During the inspection five fire drill were reviewed. Out of the five fire drills reviewed one did not have the designated meeting area..	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, we observed one of the three children's med log records reviewed lacked the signatures of the administering staff.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the inspection, I observed the professional test for the smoke detectors was six days overdue.	—
4	—	748.931(b)(2) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 1 hour normalcy. During the inspection, we observed two of four employee records reviewed lacked proof of annual Normalcy training.	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 the refrigerator and freezer in the cottage to be lacking thermometers. The house parent replaced the thermometers while I was present.	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 monitoring inspection, it was observed that the refrigerator in Cottage A did not have a thermometer.	—
2	—	748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting On two of the child plans, the implementation date was marked to be 10 days before signatures, and one plan showed an implementation date that was 28 days before the parties signed the plan.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container One of the First Aid Kits had numerous packets of medication, which are required to be locked.	Yes
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 During the inspection, I observed four of four employee records reviewed lacked Affidavit Form 2912.	—
4	—	748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material During the inspection, we observed the loose fill under the playground equipment was between 3.5-5 inches in depth.	—
4	—	748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection The Health and Sanitation inspection was due earlier this month. The most recent inspection was done on 8/8/2022 .	—
4	—	748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model In reviewing the medication logs for Cottage A they did not have a updated medication log for the children in care.	—
2	—	748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results On one dental exam, the bill and pictures of teeth were in the file, but there was no explanation of what was done or who the Dentist was.	—
2	—	748.3273(8) - First Aid Kits-Each one must contain thermometer The main vehicle for the cottage did not have a thermometer in the First Aid Kit.	Yes
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. Three of the four employee files read did not contain certificates for Medication of 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 inspection, I observed the operation has not had a fire inspection in over 1.5 years.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication During the after hours walkthrough, I observed three of four prescription medication logs lacked the reason the medication was prescribed.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled at a foster child on more than one occasion. He also put his hand on the younger sibling's neck while guiding him to his bedroom.	—
3	—	748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available Three of the four children's records showed that the initial medical exams were done 4, 3, and 2 days late.	—
3	—	748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required During the monitoring inspection,the operation did not have documentation that the automatic fire alarm system in Cottage A had been tested within the previous 12 months.	—
5	—	748.2101(1) - Medication Storage-Store medication in a locked container During the inspection of Cottage A medication was found not be stored in a locked container.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, I observed several medication logs to have entries with the initials of an individual administerinig the meds but no full name or signature.	—
3	—	748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care During the inspection, we observed two of two first aid kits reviewed lacked the first aid guide.	—
3	—	748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below During the monitoring inspection, it was observed that the freezer in Cottage A did not have a thermometer.	—
1	—	748.1385(7) - Service Plan Review-Must update the estimated length of stay and discharge plans, if changed During the inspection, we observed three of three service plan updates reviewed lacked updates to the estimated length of stay. The children have exceeded the length of stay estimated in the admission assessment.	—
3	—	748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights During the inspection, we observed two of three child's rights reviewed lacked documentation of the date reviewed with the child.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name During the Inspection, we observed two of three children's medication logs lacked documentation of the prescribing doctor's information on the form.	—
3	—	748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care During the inspection, we observed two of two first aid kits reviewed lacked the first aid guide.	—
3	—	748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes During the inspection five fire drill were reviewed. Out of the five fire drills reviewed one did not have the designated meeting area..	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication During the inspection, I observed several medication logs to have entries with the initials of an individual administerinig the meds but no full name or signature.	—
4	—	748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication. Three of the four employee files read did not contain certificates for Medication of Administration.	—
2	—	748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves During the inspection, I observed one of two first aid kits reviewed lacked a pair of waterproof gloves.	—
3	—	748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below During the monitoring inspection, it was observed that the refrigerator in Cottage A did not have a thermometer.	—
3	—	748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available Three of the four children's records showed that the initial medical exams were done 4, 3, and 2 days late.	—
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 the refrigerator and freezer in the cottage to be lacking thermometers. The house parent replaced the thermometers while I was present.	Yes
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs During the inspection, we observed three of three service plan updates lacked evaluations of effective strategies and goals for the children. The service plans also lacked evaluation of Normalcy services.	—
2	—	748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results On one dental exam, the bill and pictures of teeth were in the file, but there was no explanation of what was done or who the Dentist was.	—

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

Inspections (80)

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

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