Severe reports

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.

Kiva Treatment Center UT

Inspected January 18, 2024 Physical abuse or assault

The provider was out of compliance with this rule by failing to report multiple allegations of verbal and physical abuse to the applicable investigative agencies. During the investigation inspection, interviews disclosed allegations of verbal and physical abuse by staff members.

During an investigation inspection, multiple interviews substantiated that a staff member made verbal threats to a client and punched a hole in a hallway wall.

From the state's report. Out of compliance, focus inspection. Cited: R495-876-6(1)(a)-(g) Client rights.

BCL Partners: Leading Youth for Excellence (Lyfe) PA

Inspected January 17, 2024 Physical abuse or assault

On , child A was not treated with fairness, dignity, and respect by staff member A. Specifically, the child was provoked by staff, shoved to the floor and was carried in an unapproved restraint.

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

VISTA MAREA CA

Inspected January 10, 2024 Physical abuse or assault

Specifically, it was reported that two staff members threatened to spank [Child 2] and [Child 3].

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

St Peter - St Joseph Childrens Home Emergency Shelter TX

Inspected January 8, 2024 Physical abuse or assault

Video surveillance shows staff pushing a child.

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.

Texas Hill Country School TX

Inspected January 8, 2024 Physical abuse or assault

Through interviews with staff and children in care, it was determined that a staff member slammed a child in care to the ground when performing a restraint on the child.

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.

Newport Academy-Lodge NC

In plain words: A former client said two staff members sexually assaulted her while they were trying to get her phone back. The report says there is no documentation of an investigation or of protective measures being put in place. Our summary of the state's report. The state's own wording follows.

No documentation of an investigation into the allegations made by Former Client (FC) #7 that Staff #3 and Staff #4 sexually assaulted her on No documentation to support systems were put MHL0601558 Be WING 01/03/2024 in place to protect clients during an investigation after sexual assault allegations were made against Staff #3 and Staff #4 on 10/20/2023. [...] Description: Client ([Former client 7]) stated that staff (Staff #3 and Staff #4) were sexually assaulting her when staff were trying to get the phone back from the client. [...] Type of incident: Client/Staff Sexual Assault Allegation. Synopsis of incident: On Friday 10/20/2023 Client ([Former client 7]) stole staff phone and ran into her bathroom... and was making statements that staff (Staff #3 and Staff #4) were sexually assaulting her while she was in the bathroom. [...] The allegation of sexual assault incident with [Former client 7] occurred on 10/20/2023.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 132 G.S. 131E-256(G) HCPR-Notification,. "[...]" 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.

SCOTT'S YOUTH FACILITY II CA

Inspected January 3, 2024 Physical abuse or assault

Interviews conducted with children had similar statements and stated that a staff grabbed and pulled a child's hair and staff punching a child in the back after children threw water and condiments at staff. [...] Staff stated there was an incident that occurred where a child threw soap and water at a staff.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

Special Parent Advocacy Group A NJ Nonprofit Corporation TX

Inspected January 1, 2024 Physical abuse or assault

Child in care was hit by a staff member.

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.

Cinnamon Hills Youth Crisis Center UT

Inspected December 26, 2023 Physical abuse or assault

During an investigation inspection, staff and client interviews and provider documentation substantiated that a staff yelled at a client, grabbed the client by their shirt, shook the client, and hit the client in the forehead with an open palm.

From the state's report. Out of compliance, focus inspection. Cited: R495-876-5(1)(a)-(m) Code of conduct.

Adelphoi Village: Middle Creek III PA

Inspected December 23, 2023 Physical abuse or assault

On ma. child A was in an inappropriate physical altercation with staff member A. Staff member A is seen on video pulling back multiple times to punch the child in the midsection.

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

Texas NeuroRehab Center TX

Inspected December 20, 2023 Physical abuse or assault

A child in care was hit and choked by a staff member.

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.

NEW BEGINNINGS RESIDENTIAL TREATMENT FAC.- RAJA CA

Inspected December 18, 2023 Death Physical abuse or assault Self-harm

As a result, [Child 1] was found unconscious from an overdose and later passed away. [...] As a result, [Child 1] suffered an overdose and loss of life while under the direct care of STRTP [Staff 4]. Pursuant to the Enhanced Civil Penalty law, the Health and Safety Code 1548 (e)(3) states a violation the Department determines "resulted in the death of a person receiving care through a short term residential therapeutic program" the Department will issue an immediate civil penalty of $7,500.00. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.

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.

Fostering Life Youth Ranch, LLC TX

Inspected December 2, 2023 Physical abuse or assault

A caregiver shoved a child in care on the shoulder during an argument.

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..

Crossroads Group Home for Boys PA

Inspected November 17, 2023 Physical abuse or assault

During the course of an investigation, it was determined on /2023 that Staff Member A engaged a verbal conflict with Child A, including using profane language, and staff pushed the back of the child's chair, causing to fall to the ground.

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

REM CALIFORNIA, LLC - TOPAZ CA

Inspected November 15, 2023 Death Physical abuse or assault

The Penal Code Section 11165.6 defines child abuse or neglect as a physical injury or death inflicted by other than accidental means upon a child by another person. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the Facility Director.

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

Bayes Achievement Center TX

Inspected November 14, 2023 Physical abuse or assault

Staff was observed on video hitting a child in the face with a closed hand.

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..

Youth Health Associates dba Lakeview UT

In plain words: A report noted several serious incidents in the program, including a medical emergency from suspected drug use, aggressive physical restraints by staff that caused injuries, sexual misconduct, criminal activity, and a child leaving without permission. Our summary of the state's report. The state's own wording follows.

These incidents included a client medical emergency as a result of reportedly smoking methamphetamine, an unnecessary and aggressive physical restraint that resulted in serious client injury, a physical restraint in which a staff punched a client in the face multiple times that resulted in client injury, 5 incidents of client sexual misconduct, criminal activity, and an AWOL incident.

From the state's report. Out of compliance, complaint, focus inspection. Cited: R501-1-11(2)(a)-(f) Licensed Program Complaints and Critical Incidents.

KidsPeace National Centers: Franklin House PA

Inspected November 13, 2023 Physical abuse or assault

Child B was mistreated by Staff member A when staff member A dragged the child by the arm briefly during an escalated incident.

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

PEOPLE'S CARE RESMAR CA

Inspected November 8, 2023 Physical abuse or assault

[Staff 1] offered [Child 1] the bottled water, poured water on [Child 1]'s face causing [Child 1] to escalate, attacking [Staff 1] and bit [Staff 1]'s leg.

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.

Region V BOCES (C-V) WY

Inspected November 7, 2023 Physical abuse or assault

It is alleged that an organization staff member used and unapproved restraintAtransport technique, dragging a youth on the floor to a timeout room.

From the state's report. Evidence supports non-compliance, DFS notice. Cited: Section 25 Emergency Safety Interventions; Section 23 Child and Family Rights.

Miracal's Place TX

Inspected November 2, 2023 Physical abuse or assault

A youth in care was found to be physically abused by a 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.

BCL Partners: Leading Youth for Excellence (Lyfe) PA

Inspected November 1, 2023 Physical abuse or assault

On , Child A was not treated with fairness, dignity and respect by Staff Member A. Surveillance footage showed Child A was carried in an unapproved restraint causing Child A to fall out of clothing.

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

Bison Creek Treatment Services OK

Inspected October 26, 2023 Physical abuse or assault

Additional Non-Compliance Found During Investigation: Behavior Management: Staff member used improper restraint techniques in dealing with a resident's behaviors.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-154.2(d) Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have ....

CHILDREN'S HOME OF STOCKTON TRI-PLEX CA

Inspected October 19, 2023 Physical abuse or assault

LPA's observation, interviews conducted, and records reviewed were consistent that a facility employee inappropriately handled a client in care when the client was shoved. Evidence, including interviews, incident and Law Enforcement reports, video footage, and the facility's completed internal investigation, revealed that a facility employee ([Staff 2]) shoved a client during an incident on 06/21/2023. Additionally, the video footage obtained and reviewed clearly shows the alleged staff forcefully shoving a client.

From the state's report. Substantiated. Cited: 87072(c)(11). 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.

Easterseals Gammon Academy at Zachary Road NH

The complainant’s statement that Resident A reported to emergency room staff that a peer sexually assaulted them.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.20(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 ....

Integrated Treatment Services NC

Inspected October 12, 2023 Sexual abuse Physical abuse or assault Self-harm

In plain words: The state found that two staff members, a house manager, and the licensee neglected the needs of two former clients after one reported being sexually assaulted by the other. Staff did not get medical care for the victim and doubted the report. Our summary of the state's report. The state's own wording follows.

Finding #5: Evidence Staff #1, Staff #5, the HM, and the Licensee neglected [Former client 2] and [Former client 3]'s needs after an allegation of sexual abuse made by [Former client 2] against [Former client 3]. [...] "Allegation of sexual abuse reported 9/10 (9/10/23) ...Additional steps of safety plan were taken. [...] No medical care or evaluation completed after an allegation of sexual assault and vaginal penetration with a make-up brush. [...] On 9/9/23 between 9:30 pm and 1:00 am "She [Former client 3] raped me. ..." [...] Reported the sexual assault on 9/10/23 to Staff #1 and Staff #5, "They didn't really believe me." [...] Had [Former client 2] and [Former client 3] write a grievance and spoke to both of them about the alleged sexual assault. [...] Reported the sexual assault grievance made by [Former client 2] to the HM on 9/11/23. [...] On 9/10/23, Sunday, [Former client 2] said to her '[Former client 3] raped' her ... told her she had to talk to [the Licensee] ..."

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. "[...]" 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.

FIRST STEP TREATMENT HOME CA

Inspected October 12, 2023 Physical abuse or assault

On July 28, 2023, Community Care Licensing (CCL) received the allegation that staff handled minor in a rough manner. [...] Based on confidential interviews, the allegation that [Staff 1] handled [Child 1] in a rough manner is SUBSTANTIATED because the preponderance of evidence standard has been met.

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.

The Village House NC

Inspected October 11, 2023 Physical abuse or assault

Staff #1 grabbed Client #1 by the shirt from behind with one hand and walked him over to a chair, then shoved him down into the chair; [...] Staff #1 grabbed Client #1 by the wrist, then tried to grab his other hand, Client #1 was moving around, Staff #1 then took about 2 steps and dragged Client #1 while Staff #1 was walking, he stopped and tried to get Client #1 to stand up on his feet, Client #1 was moving all around on the floor; [...] Staff #1 started to walk toward the outside door while he held Client #1's wrist, Client #1 fell to the floor and Staff #1 took about 6 steps while dragging Client #1 on the floor; [...] The allegations include The Village House staff choking and neglecting clients at the YMCA." [...] Staff #1 "dragged" client #1 out of the pool; [...] Staff #1 dragged the client (#1) out the back door.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.

Ramsey County Juvenile Detention Center MN

Inspected October 4, 2023 Physical abuse or assault

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 physical abuse of an alleged victim by a staff person..

Therapy Associates DBA Star Guides dba Star Guides UT

Inspected September 29, 2023 Physical abuse or assault

During an on-site investigation inspection, multiple interviews disclosed that a staff yelled, swore at, pulled and shoved a client up a hill that needed a break during a hike. Other staff present failed to intervene and prevent the staff from pulling and shoving the client and an additional staff eventually assisted the first staff in pulling and shoving the client up the hill.

From the state's report. Out of compliance, complaint, focus inspection. Cited: R495-876-5(1)(a)-(m) Code of conduct.

Fort Behavioral Health TX

Inspected September 26, 2023 Physical abuse or assault

A 16-year-old child received a bruise when the caregiver pushed the child out of the door.

A caregiver used inappropriate discipline by pushing a child when the child refused to leave a room.

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..

Pearl Youth Residence WA

In plain words: A child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

Pearl Youth Residence WA

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

REM CALIFORNIA, LLC - TOPAZ CA

Inspected September 20, 2023 Death Physical abuse or assault Hospitalisation

[Child 1] was transported to the hospital by ambulance from the facility with confusion and shortness of breath. [...] [Child 1]'s condition continued to de-escalate over time and on March 1, 2023, [Child 1] succumbed to death due to medical complications. During the week proceeding [Child 1]'s hospitalization, [Child 1] had been observed exhibiting symptoms of not feeling well while at school. Documentary evidence determined that [Child 1] died from illnesses that were contracted while in the care of the facility. [...] The Department has determined substantiated findings that staff did not provide medical attention in a timely manner contributed to [Child 1]'s death. [...] A copy of this report, Appeal Rights, and form UC 421-D(CRP) Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse was provided to Facility Representative during this visit.

From the state's report. Substantiated. Cited: 84078(b), 84064(f)(4). "[...]" 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.

Embracing Destiny Foundation RTC TX

Inspected September 18, 2023 Physical abuse or assault

A caregiver failed to adhere to a child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver physically abused 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.

New Beginnings TX

Inspected September 12, 2023 Physical abuse or assault

During an altercation between a staff member and a child in care, the staff member responded to the child posturing up to them by pushing them away from them.

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.

MCF - Red Wing MN

Inspected September 8, 2023 Physical abuse or assault

In plain words: A staff member forced a child to the ground with too much force, causing face and knee injuries. The state decided physical abuse occurred. Our summary of the state's report. The state's own wording follows.

The [the staff person] reached in and removed [the alleged victim], forcing [the alleged victim] to the ground with excessive force causing [the alleged victim] to sustain injuries to her/his face and knee. [...] Given the testimony provided through interviews with staff persons and the facility’s requirement per policy to de-escalate a potential use-of-force situation, to use the least amount of force reasonable, the physical injuries sustained by [the alleged victim], and staff persons belief that [the staff person] used excessive force or overreacted there was a preponderance of the evidence that [the staff person]’s conduct was not accidental and caused [the alleged victim] physical injury. 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 physical abuse of the AV by the SP.. "[...]" 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.

Bridgeway Home-Montgomery County Youth Services TX

Inspected September 8, 2023 Physical abuse or assault

A child in care was verbally and physically assaulted other children in care while staff watched.

From the state's report. Risk level: High. Cited: 748.685(c)(2) - Caregiver responsibility - provide a safe environment.

Promise Rose Residential Care Home, Inc. TX

Inspected August 31, 2023 Physical abuse or assault

A child in care was inappropriately restrained at the operation.

From the state's report. Risk level: High. Cited: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back.

New Hope Youth Center TX

Inspected August 29, 2023 Physical abuse or assault

It was determined that staff was pinching a child's nose to get the child get off of him.

From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child.

Three Rivers Treatment Center VA

Inspected August 17, 2023 Physical abuse or assault

Three staff pushed Individual #1 into the seclusion room, stayed at the door for two minutes, then all three staff walked away.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-960. I. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.

Adelphoi Village: Middle Creek III PA

Inspected August 14, 2023 Physical abuse or assault

During a CPS investigation of an incident involving Staff member A and Child A, the staff member shoved the desk violently that Child A was sitting in and pushed it backwards.

Staff member A shoved the desk into the room. [...] Staff A shoved Child A backwards and off balance.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights; 55 Pa. Code § 3800.202.c Appropriate Use of Restrictive Procedures. "[...]" marks text left out between sentences.

MOUNTAIN VALLEY CHILD AND FAMILY-GERBER CA

Inspected August 11, 2023 Physical abuse or assault

Regarding the allegations that staff spoke inappropriately to minor in care, and staff handled minor in a rough manner: both current and past statements from Bar Du clients support the statements from clients in this investigation regarding the way [Staff 1] has spoken to them, and physically handled them.

From the state's report. Substantiated (one of several allegations). Cited: 87072(d)(11), 87072(c)(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.

My Friend's House TX

Inspected August 11, 2023 Physical abuse or assault

A 4-year-old child was inappropriately disciplined, resulting in significant risk, when a caregiver hit a child's mouth and shove the child to the ground.

A caregiver hit a foster child on the mouth in response to the child's behavior.

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..

Wholeness Haven Inc. TX

Inspected August 7, 2023 Physical abuse or assault

Staff was observed hitting and punching a child on video.

Staff was also observed pushing the child to the floor.

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; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.

Harbor Point Behavioral Health VA

Per provider's CHRIS report #A20230324, by a preponderance of the evidence which included eyewitness statements, failure to follow policy and witness credibility, the provider substantiated the allegation of neglect when Employee #1 used an improper restraint with Individual #1 which caused Individual #1 to sustain an injury to their arm.

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..

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How a report gets on this page

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.