Severe reports

The allegation of sexual abuse to minor specifically refers to [Staff 1] having an inappropriate relationship with [Child 1]. Confidential interviews, video surveillance, and record review provided consistence evidence of [Staff 1] having an inappropriate relationship with [Child 1] which included massages, inappropriate touching and oral sex. [...] Based on confidential interviews, video surveillance, and record review, the preponderance of evidence standard has been met, and the allegations of sexual abuse to [Child 1] by [Staff 1] and [Staff 1] provided [Child 1] with a vape pen are substantiated.

From the state's report. Substantiated. Cited: 87072(C)(16). "[...]" 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.

The facility is found in non-compliance as per video review Staff 1 is seen pushing Youth A in the back of the head with his hand making Youth A’s head go face down into the carpet.

From the state's report. Violation established, special investigation. Cited: R 400.4158 Intervention standards and prohibitions.

According to the report, Resident #1 indicated that the staff members at the facility would not allow him/her to call Law Enforcement or Emergency Medical Services (EMS) for medical attention. It was further revealed that Resident #1 ran away from the facility for a short period of time. Lastly, it was reported that Resident #1 returned and waited on the facility front porch for law enforcement and EMS that brought him/her to hospital. [...] According to the report, Resident #2, Resident #3, and Resident #4 went to a truck stop where they were picked up by an adult male who brought them to a motel where six (6) men allegedly sexually assaulted them. It was further revealed that local law enforcement was called to the motel and two of the men were subsequently arrested.

From the state's report. Deficiency cited, severity D, licensure complaint survey. "[...]" marks text left out between sentences.

In plain words: { summary: A video showed a staff member punching a child in the face twice on purpose. The state found that physical abuse occurred. } Our summary of the state's report. The state's own wording follows.

Regarding physical abuse Although [the staff person] did not recall having any physically aggressive behaviors towards [the alleged victim], given that the video of the incident showed [the staff person] hit [the alleged victim] in the face with a closed fist twice which was not accidental, there was a preponderance of the evidence that [the staff person] engaged in conduct that was not accidental causing physical and/or threatened injury to [the alleged victim]. It was determined that physical abuse occurred (any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means.

From the state's report. Maltreatment determined as to neglect and physical abuse of an alleged victim by a staff person.. 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.

Lastly, Staff H revealed that Resident #3 told him/her that Staff C was pinching Resident #4 before Staff H walked up. A review on 03/24/2026, of the facility’s internal investigation dated 02/04/2026, revealed that on 01/19/2026, Resident #4 approached Staff F, threw his/her hands up, pointed to a bruise, and stated that he/she was pinched. Further review of the internal investigation revealed that Resident #6 stated Staff C lifted Resident #4’s shirt while Resident #5 was holding Resident #4 and pinched him/her. Lastly, the internal investigation revealed that Resident #6 asked Staff C why he/she had pinched Resident #4, and Staff C told Resident #6 to mind his/her business. [...] Additionally, the findings revealed that Staff C utilized corporal punishment on Resident #4 as a form of behavior management by pinching Resident #4.

From the state's report. Deficiency cited, severity G, licensure complaint survey. "[...]" marks text left out between sentences.

The [the alleged victim] was taken to the emergency department of the hospital where s/he was evaluated and diagnosed with an open displaced fracture and laceration of his/her right index finger and a laceration of the right little finger. [...] Staff persons were not permitted to push or shove youth and [the staff person] should not have closed the bedroom door without ensuring that the doorway was clear.

From the state's report. Maltreatment determined as to physical abuse of the alleged victim by the staff person.. "[...]" 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.

The restraint resulted in the child being injured.

From the state's report. Risk level: High. Cited: 748.2551(b) - EBI Implementation-The caregiver must act to protect the child's safety.

The document stated, “The client, [Resident 1], reported an allegation that staff had physically hit [Resident 1] and caused a mark. [Resident 1] further stated that [Resident 1]intended to present this claim at school. [...] On March 31, 2026, at approximately 6:30 AM, during the morning routine at Mattie’s Care House, LLC, [Resident 1] made a concerning statement indicating [Resident 1's] intent to report an allegation of abuse against staff. [Resident 1] stated that [Resident 1] planned to go to school and report [sic] that staff had hit [Resident 1] and caused a mark. [Resident 1] further expressed that [Resident 1] would create the mark [sic] [Resident 1] in order to support this claim. [...] 7. While on site, the Compliance Officer observed [Staff 1] conduct a phone call to the local police department.

From the state's report. Deficiency cited, complaint. Cited: R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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.

Additionally, Staff C admitted that they did not use a Safety Care escort to relocate Resident A. Review of video footage of the event confirmed that Staff C pushed Resident A across the room and down onto a couch.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(b)(11) Program staff shall not use rough handling on residents, including but not limited to, grabbing, pushing, pulling, and dragging..

Multiple children and staff witnessed staff put a child into a chokehold.

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..

On 2/18/2026, a staff member punched a client. The client was injured and got stitches in their mouth.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights.

In plain words: { summary: The state found the agency broke rules because a staff member saw another staff member use physical force on a youth on two separate occasions and fail to report it. } Our summary of the state's report. The state's own wording follows.

The agency is found in non-compliance as Staff 3 reported seeing Staff 1 elbow Youth in the back of the head and then place his hands around the base of Youth’s neck on his collarbone or shoulder area and push him down to the seated position, as well as a prior restraint with a youth where he used excessive force and did not report either of these incidents as required.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4131 Compliance with child protection law;.

The video footage showed Staff A dragging Resident A from their bedroom into the bathroom by grasping the back of the resident's shirt and pulling Resident A while positioned on their hands and knees.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(b)(11) Program staff shall not use rough handling on residents, including but not limited to, grabbing, pushing, pulling, and dragging..

It was determined that a staff member had sexually inappropriate communication with a child in care.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

Based on witnesses interviewed and documents reviewed, it was determined that a staff member bit a client, resulting in injury.

From the state's report. Substantiated.

Child A admitted to resisting, so Staff person A kept shoving Child A's head back onto the floor, using forearm on child's face and hand on child's head. [...] A medical consult concluded that the staff used excessive force and the act was diagnostic of child abuse as it created a reasonable likelihood of bodily injury and would have caused substantial pain and interfered with Child A's breathing. [...] Child B reported that staff member B was punching Child B in the face during this restraint; child reported that nose was bleeding during the incident.

From the state's report. Citation, complaint inspection, licence action taken. Cited: 55 Pa. Code § 3800.32.b Specific Rights. "[...]" marks text left out between sentences.

The agency is found in non-compliance as Youth C, Staff 1, Staff 2, Staff 4, Staff 5, and Supervisor all reported Staff 5 pushed Youth C against the wall which is not an approved restraint technique and is against Wolverine Center Policy.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

The operation failed to demonstrate prudent judgment by placing a child in care identified to have a sexual behavior problem with a roommate, resulting in a disclosure of sexual abuse by the collateral child.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

Upon review of CHRIS entry A-20250006: Entity # 1's disposition received revealed the following: Individual #1's account of the incident was consistent regarding the inappropriate restraint which resulted in injury to Individual #1.

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..

The following was discussed: In November 6, 2024, the Facility had a serious incident that occurred, which subsequently resulted in the death of a youth in care. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately resulted in death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

The complainant reported that Resident A had been forced to perform oral sex by Resident B. The licensing coordinator reviewed the Incident Reports (IR) for both residents and interviewed four staff members who were present in the building at the time of the incident.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.14(a) Program staff shall provide care and supervision at all times to ensure that residents are safe and that their needs are met according to their ....

Type of Incident: "suicide attempt, suicide gestures, self-harm, aggression, property damage;" [...] At approximately 1:55 PM, law enforcement arrived and assumed control of the scene. [...] At approximately 2:05 PM, Emergency Medical Services (EMS) arrived. Law enforcement escorted the client to he ambulance. [...] AP arrived at the facility when [Client #1] was getting ready to be transported by EMS to the local hospital on 1/4/26; "She (Executive Director/Licensee) told me to tell the police that the other staff was gone to get something to eat" on 1/4/26;

Psychiatric hospitalization or crisis stabilization admission; [...] On 1/4/24, Staff #1 was at the facility alone with Client #1, when she started to have Cc aggressive behaviors, and inflicted self- harm by cutting herself with glass. [...] EMS transported client to local hospital.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.; V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" marks text left out between sentences.

On October 13, 2025, an allegation was made that staff member [Staff 2] struck client [Child 1] on the chest following a brief confrontation. [...] The allegation that [Staff 2] hit a minor in care is substantiated.

From the state's report. Substantiated. Cited: 87072(c)(16). "[...]" 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.

Staff L stated that "training was minimal" for new staff, and that many times staff "just got thrown in" with no training.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.19(n)(1) The licensee shall educate personnel about the needs and services required by the residents under their care and document such education to ....

Specifically, it was reported that [Staff 2] shoved a paper in [Child 1]'s face and smacked the tablet from [Child 1] and swung at [Child 1].

From the state's report. Substantiated. Cited: 87072(c)(1). 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.

The agency is found in non-compliance as per youth and staff interviews, documentation and video reviewed Staff 1 punched Youth A during the incident on 12/10/2025.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

In a review of the investigation, it was found that a caregiver pushed down on a child's face.

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.

Review on 11/26/25 and 1/16/26 of law enforcement call log from 9/1/25 through 1/13/26 revealed: [...] 9/20/25, 18:21 (6:21pm), MP-RUNWY (missing person-runaway) REPORT; [...] 12/11/25 13:27 (1:27pm), DV-ASLT (domestic violence-physical assault), SUSP-SCN; [...] 9/18/25, client #3 eloped, submitted on 9/22/25. 9/22/25 client #3 eloped, submitted on 10/2/25. [...] Purpose of Investigation: The purpose of this investigation is to review and assess allegations made by consumer, while in hospital for behaviors. [Client #2] alleged inappropriate staff conduct, including inappropriate touching, staff being under the influence of drugs, and staff fighting while on duty.

From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 367. "[...]" marks text left out between sentences.

Video surveillance showed that an improper restraint was utilized by staff member A, causing the child's in a forceful manner.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.

Interviews conducted confirm a staff member yanked client by their hair and forcefully grabbed minor into a restraint to which the client felt like they could not breathe.

From the state's report. Substantiated (one of several allegations). Cited: 87072(c)(16).

Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

In plain words: { summary: State reviews showed past facility incidents. These included youth engaging in sexual acts on social media, self-harm, running away, physical fights, hospitalizations for suicide concerns and pregnancy, and crisis center calls. } Our summary of the state's report. The state's own wording follows.

Review on January 14, 2026 at 1:30 p.m. of a list of significant incidents reported by the facility in the previous 36 months to another state entity revealed the following reportable incidents: 1) On 3/30/23, a youth was caught performing sexual acts with men on social media. [...] 3) On 6/20/23, a youth was taken to the hospital for cutting his/her arms and legs. [...] 8) On 9/26/23, a youth ran away from work. [...] 10) On 10/11/23, a youth was taken to the hospital for treatment due to a physical altercation with another youth. [...] 13) On 12/4/23, a youth was taken to the hospital for suicidal thoughts and statements. [...] One youth was taken to the hospital to be checked out due to being pregnant. [...] 22) On 3/24/24, a local crisis center was called due to youth cutting his/herself and swallowing glass. [...] 28) On 6/25/24, a youth was 1013’d for suicide attempt. [...] 42) On 10/21/25, a youth was 1013’d for attempting suicide.

From the state's report. Deficiency cited, severity E, licensure complaint survey. "[...]" marks text left out between sentences.

In plain words: { summary: A child in the program used a razor to self-harm after staff talked with her. A former child in the program left the group home, returned, and used a rusty nail to self-harm. } Our summary of the state's report. The state's own wording follows.

10/10/25- Client #3's self-harm incident. 10/17/25- Client #3's AWOL, police involvement and hospitalization. [...] 10/31/25- [Former client 4]'s AWOL, police involvement and hospitalization incident. [...] The staff called the non-emergency police line." [...] The staff continued to process with [Client #3]. [Client #3] ate breakfast and went back to her room. [Client #3] kept her personal razor and broke the razor out of it, using it to self-harm. [Client #3] walked back up to the staff, showing them her arms. [...] After talking with them, [Former client 4] went AWOL at 6:47 pm and was brought back to the group home by [Local County] EMS (Emergency Medical Services) around 7:30 pm. [...] Once back at the group home, the staff monitored and followed [Former client 4] throughout the house. [Former client 4] found a rusty nail while she was AWOL the first time and used that to self-harm. [...] Staff reported that [Former client 4] hit the tree and the ground hard.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367| 27G .0604 Incident Reporting Requirements. "[...]" 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.

The facility is found in non-compliance as per interviews conducted, video reviewed, and documentation reviewed, Staff 1 got into a physical altercation with Youth A, which included Staff 1 punching and pushing Youth A multiple times.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

A staff was recorded on video pushing a child forward.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment..

Staff 1 acknowledged pushing Youth A in an attempt to de-escalate the situation and protect herself; however, physical contact in the form of pushing a resident is prohibited under the agency’s Behavior Management Protocol and applicable CCI regulations.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

The agency is found to be in non-compliance as per interviews, documentation and vide review, it was found that Staff 1 punched Youth A in his face and pulled on his hair.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

A staff threatened to physically assault a child in care.

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.

I child in care was subjected to corporal punishment by a caregiver.

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..

It was reported that [Child 1] was pushed by [Staff 3] at the facility.

From the state's report. Substantiated. Cited: 84072(d)(1). 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.

The agency is found in noncompliance when Staff 1 punched Youth A on 11/04/2025 as stated by Youth A and shown in the video.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Lastly, it was noted that Staff B also grabbed Resident #1 by the hair dragging him/her to the closet, ripping out Resident #1’s hair and scratching Resident #1’s body.

From the state's report. Deficiency cited, severity G, incident survey.

In plain words: { summary: A child in the program alleged that one staff member slapped her in the face before two staff members put her in a restraint. The state found that the child was scratched during the restraint, and there was no record of an internal investigation. } Our summary of the state's report. The state's own wording follows.

There was no documentation of an internal investigation for the incident that took place on 11/9/25 when Client #7 alleged Staff #5 slapped her in the face before Staff #5 and Staff #6 put her in a restraint for aggressive behavior. [...] "[Client #7] pushed her (Staff #5) back and [Staff #5] slapped her (Client #7)." [...] "After she (Staff #5) slapped [Client #7], they (Staff #5 and Staff #6) tried to restrain her (Client [...] Cc "[Client #7] pushed [Staff #5] and [Staff #5] slapped her in the face." [...] She was restrained for being aggressive and she received the scratch on her face while being combative during the restraint."

On 11/9/25 Client #7 had to be restrained due to aggressive behavior, and alleged Staff #5 slapped her in the face causing a scratch on her (Client #7) cheek. [...] It was determined Client #7 was scratched on her face due to a restraint. [...] On 11/9/25 Client #7 alleged Staff #5 slapped her and scratched her cheek. [...] Based on Client #7's history of assaultive behavior, she determined that "[Client #7] scratched herself as she struggled with staff (Staff #5 and #6) during the restraint." Cc

From the state's report. Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint survey. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect; V 132} G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.

"[Staff #1] called out my name and crawled under and went back to my stall and hit my head on the toilet paper thing." [...] "Three minutes later [client #2] came out, running out of the bathroom saying that [client #3] raped him in the bathroom. [Client #3] said the opposite that [client #2] tried to rape him." [...] "Staff full name: [staff #1]" Review on 11/20/25 of [Former client 5]'s medical records from local urgent care revealed:

From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 293] 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" 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.

This report is regarding the death of a 14-year-old male client ([Child 1]), which reportedly occurred on October 28, 2025 at the facility. [...] Upon arrival, the Paramedics took over care of [Child 1] and transported [Child 1] via ambulance to the hospital, while FM proceeded to the hospital as well. [...] Hospital medical staff, along with a hospital social worker, informed facility staff and the [Child 1]'s mother that resuscitation efforts were unsuccessful, and [Child 1] was pronounced deceased. [...] The facility administrator acknowledged that the client's death was not reported to Community Care Licensing as required. [...] During the Case Management incident inspection, the Department obtained information regarding the death of a client while in care at the facility.

From the state's report. Deficiency cited at inspection. "[...]" 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.

Video observation also reveals Staff 1 pushing Youth A into the wall and grabbing his upper shoulder area.

From the state's report. Violation established, special investigation. Cited: 400.10169.

The agency is found in non-compliance as per youth and staff interviews and documentation reviewed Staff 1 kicked and pushed Youth A during the incident that occurred on 10/20/2025.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Behavior Management: Staff member used improper restraint technique including wrapping his arms around the resident's neck.

From the state's report. Substantiated complaint. Cited: 340:110-3-154.2(d) Physical restraint. Restraint is used only when less restrictive interventions, per program policy, were attempted or ....

The purpose of this inspection was to deliver findings for a serious incident which had resulted in a client's death in November 2024. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately had resulted in a client's death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

It was observed a staff member used excessive force to initiate a restraint by grabbing a child in care's arm from behind and swinging them into a door.

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.