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.
Allegations involving inappropriate sexual comments made by a staff member were not reported timely to Licensing.
From the state's report. Risk level: Medium High. Cited: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child.
On 9/22/24 Client #1 tried to elope and was laken to the hospital for evaluation. [...] Client #1 told hospital staff that Staff #1 pushed her and denied her water. [...] Staff #1 came and pushed her back into her bedroom.
From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 132) G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.
The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.
From the state's report. Risk level: High. Cited: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain.
During the incident, the provider failed to conduct physical in person 15 minute checks on the client and the client was later found unresponsive.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
Based on information obtained a preponderance of the evidence was found that staff handled minors in rough manner during restraints.
From the state's report. Substantiated.
On 5/13/2024, Community Care Licensing Division (CCLD) received an allegation that on 4/24/2024, Client ([Child 1]) was transported to the hospital following an attempted suicide by hanging with a belt (refer to LIC811, dated 10/15/2024). [...] Staff on duty brought [Child 1] down and performed cardiopulmonary resuscitation (CPR) until paramedics arrived. [Child 1] was resuscitated, transported to the hospital, intubated, and diagnosed with Hypoxia. [...] Based on confidential interviews, record review, and analysis of circumstances, the Department has determined that the preponderance of evidence standard has been met; therefore, the allegation that staff did not provide necessary care and supervision to [Child 1] resulting in [Child 1]'s attempted suicide by hanging with a belt while in care is substantiated.
From the state's report. Substantiated. Cited: 84078(b). "[...]" 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 an incident on 09/26/2024, a staff member engaged in an inappropriate sexual conversation with multiple clients.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
It was determined that a caregiver choked a child to where they couldn't breathe.
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.
Staff (Staff #1) then tried to open the door and realized that there was something pushed a against the door. [...] "Arrestee Information: [Staff #1]. Type of arrest: Taken into custody. [...] Charge #1: Rape- 2nd degree. [...] Charge #3: Statutory rape of a child <15 or =15. [...] He (Former Client #6) then asked [Staff #1] if he wanted him to do oral sex on him. [Former Client #6] then performed oral sex on [Staff #1]. [Staff #1] ejaculated in client's mouth. [Staff #1] then cleaned himself with [Former Client #6]'s shirt. [Former Client #6] afterwards told [Staff #2] at the facility." [...] " then ran away from the home (facility) and Cc went to the police." Facility staff called the police when he ran away. He told police there was evidence. [...] Later that day, Former Client #6 informed Staff #2 about the sexual abuse. [...] Staff #1 was charged with Rape- 2nd degree, Indecent Liberties and Statutory rape of a child <15 or =15.
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 members A & B are also noted to kick the VC on back and under buttocks while the VC remained face down.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights; 55 Pa. Code § 3800.32.b Specific Rights.
Incident report received on January 5, 2024 referenced a, "need for proper follow up supervision and protocols to be implemented following the incident by requesting additional supervision...." Emails received show two on-duty staff, written up for "failure to provide appropriate supervision during your shift, which resulted in one student being subjected to three separate incidents of physical assault with three other students over the course of a two hour period.
From the state's report. Substantiated.
Staff 1 sent sexually explicit photos and videos to Youth A from her personal phone to the hidden phone at the facility.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4112 Criminal history check, subject to requirements; staff qualifications.
Multiple children advised of being hit by staff.
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..
In plain words: The state found that a staff member had inappropriate sexual relations with children in care. Staff also neglected supervision, which led to a child getting a staff member's firearm and being arrested. Additionally, staff left children alone at the facility and gave a child keys to access medications and other prohibited areas. Our summary of the state's report. The state's own wording follows.
During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas.
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. The state recorded it as corrected at the inspection.
The agency is found in non-compliance as per video reviewed, Staff 7 pulled Youth A by his shirt and around his waist to stop him from exiting the pod.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
Resident [Resident 1] was brought to the therapist's office at approximately 1:30-1:40. [Resident 1] disclosed to the therapist that another peer was kissing [Resident 1] and asking [Resident 1] to engage in other sexual activity.
From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose .... 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.
Page The Department received a complaint alleging staff ([Staff 1]) hosted minors at her home, fondled a client's ([Child 1]) genitals and kissed [Child 1] mouth to mouth in her bedroom.
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 staff interviews and video review, Staff 1 pushed Youth A two times during an incident on 06/29/2024.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions..
On August 16, 2023, CCL received allegations that staff physically abused residents, staff emotionally and verbally abused residents, Staff handled residents in an aggressive manner, staff employed inappropriate forms of discipline with residents, staff inappropriately restrained residents, and staff did not accord dignity to residents in care. [...] Based on the confidential interviews and documentary evidence, the Department has determined that there is a preponderance of evidence that staff [Staff 1] and [Staff 2] physically abused clients [Child 1], [Child 2], [Child 3] and [Child 4] while in care.
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.
Lastly, Staff D indicated that later that evening Resident #1 reported his/her injuries to staff and was taken to the hospital. [...] Resident #1 further stated that he/she swung at Staff B and tried gorging his/her left eye out and Staff B slammed Resident #1 to the ground pressing his/her face to the ground.
From the state's report. Deficiency cited, severity D, licensure complaint survey. "[...]" marks text left out between sentences.
Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. [...] 1. A review of [Resident 1]' s medical record revealed an incident report of a medical overdose by [Resident 1] on September 1, 2024. The report stated "At med pass, [Resident 1] was given [Resident 1] seroquel and [Resident 1] took the bottle, emptied it into [Resident 1] mouth, and swallowed 13 or 14 tablets." The report indicated [Staff 4] contacted 911 and poison control, and [Resident 1] was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of [Resident 1]'s self-injury was not available for review.
The assessment stated [Resident 1] is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4.
From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a ...; A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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 investigation revealed, reported allegations of Youth #1 being inappropriately touched by former staff member ([Staff 1]) was previously investigated by the San Luis Obispo Police Department in February 2020 and the matter was closed. In September of 2020, the same allegation of being inappropriately touched by [Staff 1] was investigated by CCL Investigator Mariana Lomeli and substantiated regarding [Staff 1] sexually abusing minors in care.
From the state's report. Substantiated (one of several allegations). 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 youth program supervisor stated a child in the program reported a staff member pushed and hit the child. Our summary of the state's report. The state's own wording follows.
3. A review of [Resident 1] ' s medical record revealed a document titled "Florence Crittenton Internal Investigation Report." The report included a "Summary Timeline of Events" which stated, "Tuesday, September 3, 2024, On Sunday, September 1st, 2024, Youth Program Supervisor [NAME] notified [Staff 5], [Resident 1 ' s] grandmother called the Campus Lead ' s phone, stating, "[Resident 1] reported staff pushed [Resident 1] and hit [Resident 1].
From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. 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.
At approximately 9:35 AM, via video in hallway footage, two male staff members were seen dragging Client #1 from the seclusion room holding the client under both arms, two female staff members were following.
A review of the emergency safety intervention justification packet dated 08/11/2024 at 1715 [5:15 PM] with a physical and chemical restraint safety intervention implemented revealed Client #3 received an injury due to improper technique of the applied physical restraint. [...] Client #3 during the video review of the emergency safety intervention, it revealed client was pulled from the melee at 5:21 PM and placed into a physical restraint, then received a chemical restraint at Client #3 was interviewed on 8/28/24 1:21 PM and indicated an injury to the right side of the head that occurred during the emergency safety intervention.
From the state's report. Deficiency cited, complaint survey. Cited: N 126 PROTECTION OF RESIDENTS N 126; N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
In an interview, [Staff 1] acknowledged residents were admitted to the behavioral health residential facility with previous sexual abuse as well as residents with previous sexual aggression.
From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or treatment, or verbally or physically interact .... 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 the information that this LPA was able to gather the allegations that client was confined to his room, that staff handled client in a rough manner and that [Child 1] was inappropriately supervised are substantated.
From the state's report. Substantiated. Cited: 84078(b), 84072(d)(23). 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 reported that a youth stated staff pushed him into a dresser on 6-27-2024, however it was not Reported reported to DFS until 7-2-2024 .
From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 3 Abuse and/or Neglect Reporting.
On , child A was mistreated by staff member A. Staff member A inappropriately restrained child A resulting in a scratch on child A face.
On , child A was placed in a restrictive procedure that was used as a program substitution to restrain Child A. Staff member A inappropriately restrained child A resulting in a scratch on child A face.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights; 55 Pa. Code § 3800.202.a Appropriate Use of Restrictive Procedures.
On , child A was mistreated by staff member A due to staff member A performing an inappropriate restraint.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.
While reviewing video footage a staff was observed twisting a child's arm behind their back during an improper restraint.
From the state's report. Risk level: High. Cited: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back.
A caregiver physically pushed and used a close fist to punch a child in care.
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.
The agency is found in non-compliance as interviews with Youth A, Supervisor 1 and Supervisor 2 confirm Staff 1 hit Youth A in the face. Additionally, Supervisor 3 reported Staff 1 informed her Staff 1 hit Youth A.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Criminal history check, subject to requirements; staff qualifications.
The staff member pushed the client causing the client to fall into a bed frame.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
In plain words: Medical records showed one child went to the hospital after an injury and was put on meal lockouts and frequent checks. Another child was taken to the emergency room due to self-harm, and the state requested an internal investigation. Our summary of the state's report. The state's own wording follows.
Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. [...] Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1.
From the state's report. Deficiency cited, complaint. Cited: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health .... "[...]" marks text left out between sentences.
The facility was found in non-compliance as per staff and youth interviews and video review, Staff 1 pushed Youth A multiple times and threw Youth A to the side during the escalated incident that occurred on 05/18/2024.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
During the inspection, the investigator observed via video footage a staff aggressively shove a client in the back acting outside of their behavior management training.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
A staff member admitted to hitting a child in care.
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..
Multiple children reported staff driving recklessly- speeding, going off the road, and almost hitting a barrier.
From the state's report. Risk level: High. Cited: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance.
During the investigation, LPA interviewed staff and clients which revealed that staff handled minor in a rough manner.
From the state's report. Substantiated.
During the investigation, there were multiple accounts of a caregiver pushing a child in care.
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..
The department received information that Staff D physically abused a resident in response to the resident's behaviors.
From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(b)(1) Program staff shall not abuse or neglect residents..
Any injuries resulting from the use of restraint and seclusion procedures; c.
From the state's report. Violation cited by DHS.
For example: 1/2/24 Two youths eloped, stole a vehicle, hit a pole and rolled the vehicle multiple times. 1/28/24 A child eloped and stole clothing and jewelry from Wal-Mart. 1/4/24 A child eloped, stole alcohol, was observed by law enforcement to be intoxicated and trying to break into a house. 1/5/24 A child eloped. 1/6/24 Another child eloped, stole monster drinks and Tylenol from Wal Mart returned to the facility and stated she overdosed on the Tylenol. [...] 3/11/24 A child eloped. 3/11/24 A child eloped and upon return reported she was stabbed, tased and sexually assaulted by a man. 3/12/24 A child eloped. 3/19/24 Three children eloped. 3/20/24 Two children eloped. 3/22/24 Two children eloped together. 3/24/24 Three children eloped together. 3/9/24 A child eloped. 3/31/24 three children eloped, stole alcohol and tested intoxicated. 4/1/24 Four children eloped and stole alcohol. [...] 4/16/24 A child eloped.
From the state's report. Deficiency cited. Cited: 16.04.18.207 QUALITY OF SERVICES. An organization must carry out its licensed programs in an environment that is safe, accessible, and appropriate for the .... "[...]" marks text left out between sentences.
It is alleged that on July 8", 2024, an organization's staff, used an unapproved physical restraint technique, resulting ina physical strike to the youth, causing a Aliegation: bruise.
From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 25 Emergency Safety Intervention; Chapter 3, Section 23 Child and Family (Parent, Guardian) Rights; Chapter 3, Section 24 Disciptine.
The agency is found in non-compliance as interviews and video footage verified that Staff 1 pushed Youth A to the ground.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4157 Behavior management.
The Department received a complaint on September 21, 2023, alleging staff pushed child. [...] Confidential interviews revealed that [Staff 1] admitted [Child 1] came towards [Staff 1] and in self-defense [Staff 1] pushed [Child 1] away and [Child 1] fell and hit [Child 1]'s back. Based on interviews and record review, the preponderance of evidence standard has been met and the Department has determined that [Staff 1] pushed [Child 1].
From the state's report. Substantiated. Cited: 84072(c)(15). "[...]" 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 agency is found in non-compliance as per video review, youth interviews, and staff interviews, Staff 1 punched Youth A in the face which is prohibited.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
In plain words: A staff member bit a child on the shoulder to make the child let go of the staff member thumb. The child reported that the staff member put him in a chokehold and threw him on a bed, and that the child bit the staff member to get away. Another staff member called the police, and the child went to the hospital. Our summary of the state's report. The state's own wording follows.
Staff #1 bit Client #1 on the left shoulder to get Client #1 to release his bite on Staff #1's right thumb. [...] "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Vv 514 iss Mir flo( MX 25, hon (Kasi yeahs CDK911 If continuation sheet 5 of 9 Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed: [...] Called the police and Client #1 was transported to a local hospital for a mental health evaluation for his aggressive behavior [...] In an attempt to get Client #1 to release his bite, Staff #1 bit Client #1 on the left shoulder.
"He (Client #1) said [Staff #1] pulled him by the shirt and threw him on the bed, breaking the bed, then he (Client #1) grabbed a piece of wood from the broken bed and defended himself against [Staff #1]." "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Client on Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed:
From the state's report. Deficiency cited, complaint survey, Type A2 violation. Cited: V514 ugetn; V 514) 27E .0102 Client Rights - Prohibited Procedures Vv 514. "[...]" marks text left out between sentences.
Based on confidential interviews, observations, and record review, including review of police investigation report and interviews with alleged victim and suspect, it was alleged that a staff member hit a resident with an open hand on the face.
From the state's report. Substantiated.
1. A review of facility documentation revealed an Arizona Health Care Cost Containment System (AHCCCS) incident report dated July 9, 2024 for an incident of sexual abuse reported on July 5, 2024. The report indicated suspected sexual abuse of [Resident 1] by [Staff 5]. The report stated "On 7/6, the member reported to a staff member that on 7/5, a staff member has inappropriate sexual contact with [Resident 1]." 2.
From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. 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 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.