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 staff slapped a child in care.
A child in care was slapped by a staff member.
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.
The Incident Report noted the caregiver finding "pooled blood" on the floor of the room where the assault took place, and the child sustained a knot on their head, a bloody nose, as well as bruising.
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 review of this investigation, interviews reported that a staff member slapped a child in care during a restraint.
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: A state report found that a staff member dragged, kicked, and pulled the hair of a child in the program. The state substantiated these allegations of rough handling based on interviews and file reviews. Our summary of the state's report. The state's own wording follows.
On March 15, 2024, the Department received the allegation that staff dragged and kicked minor in care. [...] A confidential interview stated that [Staff 2] attempted to grab on to [Child 1]'s arm for a hold, however, [Staff 1] grabbed and dragged [Child 1] into the garage. A confidential interview maintained that staff kicked and stepped on [Child 1]'s foot during the dragging. Based on confidential interviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] dragged and kicked [Child 1] in care is substantiated.
It was further reported that [Child 1] stood up and charged back at [Staff 1] and [Staff 1] grabbed [Child 1] by the hair and yanked [Child 1]'s head back. [...] Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] handled [Child 1] in care in a rough manner is substantiated.
From the state's report. Substantiated; Substantiated (one of several allegations). Cited: 80072(a)(1); 80072(a)(3). "[...]" 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 following narratives are regarding two incidents at Cove Secure/White Deer Run LLC with the same violations for each incident: On child A was mistreated after being head butted and inappropriately restrained by staff member A. Video review of the incident clearly shows child A standing in the doorway alone.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.
At approximately 0:12 seconds in, [Resident 1] tried to exit the room again and [Staff 1] forcefully extended [Staff 1]'s and pushed [Resident 1] towards the middle of the room.
From the state's report. Deficiency cited, complaint. Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; B. An administrator shall ensure that: 2. A resident is not subjected to: a. Abuse;. 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 the facility, the client was out of supervision of staff and was later found unresponsive.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
The staff member pushed the child in care's chin during the restraint.
From the state's report. Risk level: High. Cited: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.
During the inspection, it was reported by witnesses that a teacher mistreated a client by pushing the client when the client was acting out in their class.
From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
While a child was being restrained by staff, another staff choked the child.
A staff threw away a child's food in response to the child spitting at their feet.
A child received a bloody, swollen nose during a restraint due to a staff member banging their head on the ground.
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; 748.2307(14) - Other Prohibited Punishments-withholding food that meets the child's nutritional requirements; 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.
During a restraint, a staff used excessive force to take a child to the ground, causing the child to chip a tooth upon impact.
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 intentionally pushed and hit a youth in care during an altercation.
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.
It was found that a caregiver dragged a child to the restroom and hit the child repeatedly in the head.
It was found that a caregiver used corporal punishment with a child 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; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
[Former client 4] stated the staff had been making "sexual advances toward him for the last 2 month."
From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 132. 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, Youth A and Staff 1’s interview, Staff 1 pushed Youth A into his room.
From the state's report. Repeat violation established, special investigation. Cited: 400.10107 Employment policies and procedures; establishment.
In plain words: A staff member placed his hand on a youth’s face, pushed the youth’s head back, and then pushed the youth backward by the shoulders near the neck, causing the youth to fall into a chair and hit the floor. Our summary of the state's report. The state's own wording follows.
Non-compliance is also found in the courtyard when Staff Person 1 placed his hand on Youth A’s face and pushed Youth A’s head back, Staff Person 1 used one hand and pushed Youth A on his back, and Staff Person 1 placed his hands on Youth A’s shoulders by his neck moving Youth A backwards, which caused Youth A to back in to a chair and fall to the ground.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions..
Received pictures the night of 1/11/24 "showing Cc Cc marks on his ([Former client 2]'s) neck ...think they were obtained during the restraint;"
From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. 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.
He came in my office last Friday and showed me and he said she (staff #1) choked me said we talked last week, and you said you were playing.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect.
Operation did not call in to report when they became aware of an allegation made by a child in care of being sexually assaulted by another child.
From the state's report. Risk level: Medium High. Cited: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child.
(continued on LIC 9099c) Specifically, it was stated that [Staff 1] grabbed [Child 3] by the shirt and pulled [Child 3] towards to [Staff 1] and [Staff 1] made an inappropriate statement to [Child 3].
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.
" called her ‘an old hag’ again and she (staff #1) said, ‘why don't you run (hit) to your old hag (repeated this twice).' asked her, ‘are you talking about my grandma?" " started crying. [Staff #2] had moved to the left side of her (staff #1). started yelling at [staff #1], ‘you do not know who you are messing with.' She (staff #1) pulled at her pants, like she was Cc squaring off (getting into a fight stance) and said, ‘you messed with the wrong one today.’ Then she (staff #1) said something, don't remember what she said, but it triggered me. punched her in her cheek. was aiming for her eye. thought had punched her in her eye but later heard her telling [Staff #2] hit her on her cheek." [...] "l walked down the hallway and yelled to [Staff #1], ‘I'm sorry [Staff #1], didn't want to hit you, _ didn't want to hurt you but you scared me.' She (staff #1) didn't respond."
From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512 27D .0304 Client Rights - Harm, Abuse, Neglect V.512 Tame diate \y ‘. "[...]" marks text left out between sentences.
Staff 2 used corporal punishment by punching and pushing Youth A. This was evident in the video watched at the facility and confirmed by both Staff 1 and Staff 2.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
It was alleged Staff hit youth. [...] On 03/08/2024, the Department received a complaint alleging that a staff hit youth. [...] [Staff 1] stated that she did not slapped or punch the youth. [...] [Child 1] stated that he spat on [Staff 1] again and [Staff 1] slapped him again. [Child 1] stated that he spat on [Staff 1] for a third time and [Staff 1] punched him on the face and kicked the PS5. [Child 1] stated that there was another staff that got there just before [Staff 1] punched him and the other kids were in the van. A second staff worker who was present and witness the incident stated that [Staff 1] punched [Child 1] on the face.
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.
A caregiver used excessive physical force by hitting a 9-year-old child with a shoe approximately three times.
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.
Individual #1 reported a sexual assault to Employee #1 involving Individual #2.
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 agency is found in non-compliance as Staff 2 adamantly reported he witnessed Supervisor W punch Youth A in the face and did not report it as required per child protection law.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4131 Compliance with child protection law; development of plan required..
A child in care was choked and punched by a staff member
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 child in care was slapped by a caregiver in the face which caused a bruise.
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.
Individual #1 was placed in a prone restraint that caused bruising and a bloody nose to Individual #1. [...] Based on the provider's investigative finding, there is a preponderance of evidence to support a substantiated finding of physical abuse.
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.. "[...]" marks text left out between sentences.
The provider failed to follow the below Joint Commission standards: Standard CTS.05.06.35 (15) The facility failed to evaluate and report the injury to Youth #3 on 11/18/2023 to external agencies when Staff #1 reported punching Youth #3 three times and gauging at his eyes.
From the state's report. Deficiency cited, complaint inspection.
In plain words: A staff member allegedly slapped and punched a child in the face, causing a bloody nose, and threw the child onto a couch during an incident over a phone call. Our summary of the state's report. The state's own wording follows.
In doing so staff hand hit clients nose causing it to bleed. [...] "[Client #4] said [staff #1] punched me and threw me on the couch and sat on him." [...] "[Client #4] kind of lunged at [staff #1] and brought back his hand to scare [staff #1]. [Staff #1] slapped [client #4] on the face and that caused him to fall back on the couch. Then [staff #1] kept slapping [client #4] in the face a pretty good amount of times.” [...] "He (staff #1) assaulted a minor and now he is working again. [...] Staff #1 hit him with an "open hand." Interview on 4/9/24 with client #4 revealed: [...] Staff #1 then "yanked" the phone out of his hands and his phone call was disconnected. [...] "I guess he (staff #1) thought was going to hit him.” "He (staff #1) slapped me with an open hand 1 time (on his face) and fell back on the couch because of how hard he hit me." [...] "[Staff #11] asked me what happened and told him [staff #1] started punching me."
From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V512, 27D .0304 Client Rights - Harm, Abuse, Neglect v512 Each staff member was required to review the. "[...]" marks text left out between sentences.
Through interviews with youth and documentation reviewed there was evidence found that Staff 1 hit Youth A during an escalated incident on 02/26/2024.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
"[Staff 2] stopped walking and stiffened his body, mostly [Staff 2]'s arm, stuck out his elbow and [Staff 2]'s elbow hit [Resident 1].
"[Staff 2] stopped walking and stiffened [Staff 2's] body, mostly [Staff 2's] arm, stuck out [Staff 2's] elbow and [Staff 2's] elbow hit [Resident 1].
From the state's report. Deficiency cited, complaint and compliance (annual). Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; 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.
The report states that | Reported the staff member has used sexually inappropriate comments that make outh feel uncomfortable. oases, [resem [rinding: [
From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 23 Child and Family (Parent, Guardian) Rights.
Behavior Management: Staff member punched resident(s).
From the state's report. Substantiated complaint. Cited: 340:110-3-154.2(b)(1) shaking, striking, spanking, or other cruel treatment;.
Through interviews it was confirmed a staff dragged a child in care by the hair to the bathroom to sprayed child off in shower as a form of punishment.
Staff used excessive force when preforming an emergency behavior intervention.
From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
A staff member hit a child in the face as a means to get the child to comply.
Collateral staff confirmed during interviews that the staff member was directed to release the child from the restraint and the child said they could not breathe.
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)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso.
Employee #1 used unauthorized physical restraint while de-escalating self-harm on Individual #1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-110. A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out..
In plain words: A child in the program reported injuries after a physical restraint by multiple staff members. The child was sent to the emergency room for an evaluation and returned the next day. Our summary of the state's report. The state's own wording follows.
(Patient # 11) was sent to Valleywise ED for further evaluation as a precaution...." A review of a progress notes for Patient # 11 dated May 26, 2023 revealed "...Resident reported injuries sustained from his continued struggling against a code gray...restraint that required multiple staff to control him...guarding/pain at his left shoulder and elbow....He will be sent to the ER this evening for evaluation...." Employee # 1 confirmed in an interview on March 28, 2024, that Patient # 11 was sent to the emergency room for an evaluation on May 26, 2023 and returned on May 27, 2023.
From the state's report. Deficiency cited, complaint. Cited: R9-10-1302. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover ....
LPA was unable to interview client 2 due to aging out of foster care and whereabouts unknown. On March 13, 2023, the Department received a complaint that alleged a facility staff has engaged in inappropriate relationships with residents and facility staff has spoken inappropriately to residents. [...] Regarding the allegation that [Staff 2] has engaged in an inappropriate relationship with [Child 1], confidential interviews confirmed [Staff 2] brought [Child 1] to their residence for a home cooked meal but documented a mall trip in the client file. [...] Based on confidential interviews, the preponderance of evidence standard has been met, and the allegation that [Staff 2] has engaged in an inappropriate relationship with [Child 1] and [Staff 2] has spoken inappropriately to [Child 1] is supported and proven by evidence, therefore the allegations are substantiated at this time.
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.
Specifically, it was reported on September 7, 2023, [Child 1], Child #2 and Child #3 were left alone upstairs in the facility at which time [Child 1] was sexually abused.
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.
ALLEGATION 1 Before six staff arrived to assist him, Staff 1 admitted he used a martial arts chokehold applied from behind Youth B. Choking a youth is considered physical punishment and prohibited by the rule.
From the state's report. Violation established, special investigation. Cited: 400.4158 Intervention standards and prohibitions.
A child in care and collateral residents reported a caregiver had pushed a child on multiple occasions while in care.
From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child.
Client #1 was sitting in a chair in the facility kitchen when staff #1 grabbed her by her shirt and pulled her off a chair causing her to fall to the floor.
From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V 512.
Review and analysis of the facility surveillance video footage capturing the incident on September 17, 2023, determined that [Staff 1] used excessive force when pushing/forcing the quiet room door open with both hands while [Child 1] was visibly positioned on the opposite side of the door. [...] Based on confidential statements and documentary evidence, the Department has determined substantiated findings for inimical conduct displayed by [Staff 1] using excessive force causing a wrist fracture to [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.
Attempted to hang self 2 x with a shower curtain, 2 years ago attempted to cut throat with glass.
From the state's report. Deficiency cited, complaint and compliance (annual). Cited: A. An administrator shall ensure that: 1. A resident is admitted based upon: b. The resident's behavioral health issue and treatment needs are within the ....
Through interviews with youth and staff and documentation and video footage reviewed, there was evidence found to show a rule violation in that Staff 1 punched back at Youth A during the escalated incident.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
One staff absconded from the facility with a minor in care, across state lines. [...] Other behaviors were reported that corroborate an inappropriate relationship between the staff and client at the facility. continued on 9099-C page Based on IB findings, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations, staff had inappropriate interactions with client in care and staff absconded with client across state lines are SUBSTANTIATED, Facility is cited per Health and Safety code 1558 (a)(2) Conduct Inimical.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
The facility is found in noncompliance as Staff 4 pushed Youth A, grabbed him, pulled him to the ground then held him to the ground.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
Through interviews with youth and staff, video footage and other documentation reviewed, there is evidence to show that Staff 1 punched back at Youth A during an escalated incident and therefore this rule was violated.
From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
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.