The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.
A child in care was inappropriately restrained leading to injuries.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A staff member grabbed a child by the arm and dragged them off a couch and down a hallway.
From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.
Records revealed that [Staff 2] was terminated for allowing [Child 1] to use [Staff 2]'s work phone on more than one occasion resulting in [Child 1] engaging in an inappropriate relationship with an adult male.
From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Staff received an RTB for physical abuse and neglectful supervision.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
On July 30, 2021, Community Care Licensing (CCL) received information that alleged facility staff pushed a child while in care. [...] Based on witness interviews and records review, the preponderance of evidence standard has been met, and the allegation facility Staff #1 pushed Client #1 is substantiated.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
During the course of this investigation, it was determined that a child in care was improperly restrained and not documented.
From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.
1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH.
3. Review of the โRoot Cause Analysisโ, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the night of the alleged sexual assault incident.
Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3).
From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0420 (13)(a), Agency policies and procedures.; WAC 246-337-075 (2)(a)(g) Resident rights.; WAC 246-337-065 (5)(a) Safety and Security..
3. Review of the โRoot Cause Analysisโ, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the night of the alleged sexual assault incident.
Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3). [...] 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH.
From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 (2)(a)(g) Resident rights.; WAC 246-337-065 (5)(a) Safety and Security.. "[...]" marks text left out between sentences.
While reviewing the video, it was observed that staff immediately put a child in a choke hold without attempting a proper restraint.
From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.
On August 31, 2021, CCLD received an allegation reporting that on August 29, 2021, Staff member #1 physically assaulted Client #1 causing injuries to [Child 1]'s neck area and possible rib fracture (See LIC811, dated March 29, 2022). [...] It was revealed on August 29, 2021, an incident occurred involving [Child 1] who reportedly displayed behavior outburst resulting in [Child 1] being restrained by Staff member #1 and law enforcement being called. [...] Based on information obtained, the preponderance of the evidence standard has been met, therefore the allegation of physical abuse is Substantiated.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
In plain words: A child in the program reported having sex with another child in the game room and closet while a staff member sat nearby with their back turned. The report also states that a staff member threw a water bottle and bumped into a child with her body. Our summary of the state's report. The state's own wording follows.
"it would be different staff." Interview on 3/28/22 with client #6 revealed: -had a hickey from her boyfriend; -client #5 was her boyfriend; -had sex with client #5 in the game room; -client #4 was with them; -staff was at the table in front of the entrance to the game room; -staff had their back to them; -had sex twice in the game room closet with client -second time staff were in the same place when she and client #5 had sex; -don't remember what staff was working; -in the closet for five minutes both times. [...] Clients #1, #2, #3, #4, #5 and #6 displayed behaviors which included sexualized behaviors, substance abuse, aggression, self-harm, suicidal ideation, impulsivity, poor boundaries and criminal activity. [...] Staff #3 threw a water bottle and bumped into client #2 with her body.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 293. "[...]" marks text left out between sentences.
On August 31, 2021, Community Care Licensing Division (CCLD) received complaint allegations concerning Staff member #1 who reportedly hit resident Client #1 with a vehicle while dropping minor off at school (see Confidential Names form LIC811, dated March 29, 2022). [...] Information obtained revealed enough evidence to prove the alleged, as [Staff 1] admitted that [Staff 1] was distracted and unintentionally hit [Child 1] with the vehicle as [Staff 1] was backing up while attempting to exit the parking lot at the School after dropping off facility clients on August 25, 2021. [Child 1] was taken to the hospital to be treated for injuries.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
In plain words: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.
8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.
From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
A staff memberยs actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
An employee was observed on video forcibly picking a child up from his chair and dragging him by his pant leg, and in another video, pushing this same child in care out of his chair onto the floor and hitting him.
A staff member used physical force to push, punch, drag and twist a childยs arm behind their back as an inappropriate response to behaviors demonstrated.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
Based on interviews, record reviews and the facility tour, it was determined that the facility staff handled youth in a rough manner, the facility staff did not prevent youths from engaging in physical altercations and the facility serves inadequate and poor quality food.
From the state's report. Substantiated (one of several allegations).
Based on the information obtained there is preponderance of the evidence to prove the facility staff shoved the minor in care and improperly restrained minor.
From the state's report. Substantiated.
The facility is in violation of the rule, as Supervisor 1 punched Youth A during this altercation.
From the state's report. Repeat violation established, special investigation. Cited: R 400.158 Discipline.
It was determined that a caregiver placed a child in a chokehold.
From the state's report. Risk level: High. Cited: 748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing.
A staff memberยs actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
It is alleged that staff became physically aggressive with a child in care and executed an improper and unwarranted restraint on the child in care which resulted in an injury.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver put a child in care at risk of physical harm when he slammed the child to the ground.
A caregiver slammed a child in care to the ground as a form of discipline which caused the child physical pain.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.
During the course of the investigation, a youth alleged that [Staff 1] hit them with a belt one evening while in their own room and out of sight of cameras at the facility. [...] The facility was cited for Personal Rights 87072(a)(11) as children have the right to be free physical abuse, intimidation, threat, ridicule, and coercion. On at least one occasion, [Staff 1] struck a youth in care with a belt. [Staff 1] also disclosed to a staff that they had punched a youth in the stomach.
From the state's report. Substantiated. Cited: 87072(a)(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
It was alleged that staff are physically abusive to a facility client, facility client sustained injuries while in care, and staff are not giving a facility client medications as prescribed.
From the state's report. Substantiated (one of several allegations).
Video footage shows Staff D threw two punches toward Youth Dโs face and chest.
From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.
All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
13 year old child in care was slapped by a caregiver and a 14 year old child was grabbed by the throat and slammed to the floor by the same caregiver.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
[Staff 1]'s inappropriate behavior escalated and at some point [Staff 1] began engaging in sexual acts having sexual intercourse with [Child 1] while at the program. [...] The Department has determined substantiated finding for sexual abuse by [Staff 1] on [Child 1].
From the state's report. Substantiated (one of several allegations). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
A child in care was subjected to corporal punishment when a staff member used physical discipline as an inappropriate response to the child's behavior.
From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.
A caregiver pushed a child to the ground.
From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.
LPA confirmed through interviews with staff and clients and record reviews that the client's injury was caused by the manual restraint. Based on the information obtained, there is a preponderance of the evidence to prove that staff violated the client's personal rights by causing injury due to a manual restraint.
From the state's report. Substantiated.
Specifically, it was reported that [Staff 1] threatened to hit [Child 1] and also called [Child 1] "bitch".
From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Excessive force was used during a restraint
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
A caregiver used hitting as a method of discipline.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
A staff wrote and sent a letter to a child in care, encouraging future sexual contact with him.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
Staff continued to put resident at risk by allowing another resident to restrain and hit the resident numerous times without removing either from the situation, resulting in the resident receiving a black eye due to the other resident striking him in the face with no intervention from Staff. [...] Due to the severity of the situation, resident was transported to the hospital because he had major cuts on his arm and lost a lot of blood.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation. "[...]" marks text left out between sentences.
In plain words: The state investigated and found it true that a resource parent had an inappropriate relationship with a youth in care, putting the safety and health of clients at risk. Our summary of the state's report. The state's own wording follows.
As a result of the interviews conducted, documentation reviewed and investigation conducted, the allegation that resource parent had an inappropriate relationship with client in care and resource parent engaged in conduct that is inimical to the health, morals, welfare, or safety of clients in the facility are SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met.
From the state's report. Substantiated (one of several allegations). Cited: 84072(d).
The sexual activity was discovered by another facility client who reported it to the staff. [...] Confidential statements obtained from one of the facility clients indicated that the sexual abuse occurred, and he screamed for help during the incident but the staff was not in the immediate vicinity according to the client.
The investigation revealed that two facility clients became involved in sexual activities on two occasions during the month of June 2021 while unsupervised behind facility buildings.
(CONTINUED) It was alleged that a facility client was sexually abused by another client at the facility due to neglect and lack of supervision. [...] The incidents became known when the client who was sexually abused informed another client who then reported to staff.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
Two children in care expressed that a staff grabbed a child in care around the neck and threw him onto the couch to stop them from potentially fighting.
From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.
On June 14, 2021, CCL received an allegation that Client #1 (see LIC811, dated 12/16/2021) was sexually assaulted by Client #2 while in care. [...] Local law enforcement was contacted by the facility.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Based on interviews and record review, there is a preponderance of evidence to prove that [Staff 1] hit [Child 3] with the door to staff office and that staff instigates incidents involving minors, therefore the allegations are substantiated.
From the state's report. Substantiated (one of several allegations). Cited: 87072(d)(10). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
A staff member pushed and yelled at a child in care.
From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.
In plain words: A staff member reportedly choked a child and bent the child's back over a sink. On another occasion, the staff member punched a hole in a child's bedroom wall out of frustration. Our summary of the state's report. The state's own wording follows.
"He (staff #8) did choke me." [...] Staff #8 punched a hole in his wall. [...] Staff #8 did not punch a hole in the wall. [...] Staff #8 choked client #1 and bent his back over the sink. [...] On another occasion staff #8 got frustrated with client #2 and punched a hole in client #2's bedroom wall.
Staff #8 had a family member that recently died from cancer. He thought staff #2 was at the facility when staff #8 punched his wall. Staff #2 punched the wall just above his head and it was patched.
Staff #8 had a family that recently died from cancer. He thought staff #2 was at the facility when staff #8 punched his wall. \- Staff #2 punched the wall just above his head and it was patched. ~ Staff #8 was also involved with an incident with client #1 in October. "He (staff #8) choked [Client #1] out."
The Licensee/Qualified professional (L/QP) was aware of staff #8 punching client #2's wall while client #2 was in his bed due to frustration from the client's behavior. [...] The DSS Social Worker did not tell him about an allegation staff #8 choked client #1.
From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation; Deficiency cited, annual, complaint, and f. Cited: V 512; V 132} G.S. 131E-256(G) HCPR-Notification,; V 512; V 366. "[...]" marks text left out between sentences.
Caregiver hit a child in the head and head butted a child because the child was not doing homework.
The caregiver placed a child in a choke hold resulting in the child not being able to breath and caused discomfort.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.; 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway.
2 caregivers used corporal punishment on children in care when they punched the child/ren.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
There was an incident report dated 3/28/21 for deceased client ([Deceased client 4]).
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
3 of the 3 children interviewed stated that a staff member pinches and pulls on the residents.
From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child.
It was substantiated that on Child # 1 attempted suicide at the facility and Staff Member A was made aware of the incident. [...] Staff Member A was indicated for abuse under the CPSL law on for causing serious physical neglect of a child for failure to provide medical care/treatment.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code ยง 3800.32.b Specific Rights. "[...]" marks text left out between sentences.
Evidence and information gathered support that a staff member inappropriately touched, provided substances to and inadequately supervised children in care.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.