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.
[Staff 1] was unable to be interviewed due to whereabouts unknown at this time. On July 22, 2022, the Department received a complaint that alleged staff placed minor in (Continued) (Continued) a choke hold.
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.
A caregiver fought and hit a child in care in the face.
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.
Staff person A precedes to lift foot and kick the child on the face/forehead area, causing the child to fall backwards.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights; 55 Pa. Code § 3800.32.c Specific Rights.
During the review of this investigation, it was found that a caregiver used a prohibited restraint on a child in care.
From the state's report. Risk level: High. Cited: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso.
In plain words: A staff member grabbed a child in the program’s lower neck near the shoulder and hit the child with keys, causing a scratch. The child saw the scratch but did not report being handled or hit. The state licensing agency found the allegations substantiated. Our summary of the state's report. The state's own wording follows.
On July 7, 2022, Community Care Licensing (CCL) received a complaint alleging that a staff handled a minor in a rough manner and minor sustained injury while in care. Regarding a staff handled a client in a rough manner allegation, it was specified that Staff #1 grabbed Client #1 in Client #1's lower neck near the shoulder area. [...] It was also stated that [Staff 1] hit [Child 1] with [Staff 1]'s keys. [...] The same interview reported [Staff 1] hit [Child 1] with her keys on [Child 1]'s body. [...] Administrator stated [Child 1] did not report being handled or hit by [Staff 1] but did observe the scratch on [Child 1]'s body. [...] Based on confidential interviews, the preponderance of evidence standard has been met, therefore, the allegations that Staff #1 handled Client #1 in a rough manner and that Client #1 sustained an injury while in care are SUBSTANTIATED.
From the state's report. Substantiated. Cited: 87072(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Caregiver observed corporal punishment of a child, and failed to intervene.
A caregiver was observed using corporal punishment on a child.
From the state's report. Risk level: High. Cited: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
Staff used unnecessary force when pushing a child before restraining her three separate times.
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.
During the investigation it was found two staff physically abused two children when completing two separate inappropriate restraints.
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.
Under Health and Safety Code section 1548(f)(1)(C)(ii), a violation that the Department determines results in physical abuse as defined in section 1548(f)(2) to a child receiving care through a STRTP, there shall be a civil penalty of $2500.00. Under H&S 1548, "physical abuse" includes neglect as defined in 11165.2 of the Penal Code, when the person responsible for the child's welfare is a licensee, administrator, or employee of any facility licensed to care for children. A copy of this report, the Confidential Names Form, Appeal Rights, and the signed LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.
From the state's report. Deficiency cited at inspection.
A staff admitted to a case worker to using an inappropriate restraint towards a child in care by placing his arms behind his back.
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.
A caregiver pulled the hair of a child in care, grabbed the child by the neck and threatened the child.
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 4/22/23, at approximately 1933 (7:33 p.m.), [Officer] responded to [County Hospital] for a sexual assault case. [Officer] spoke with [Former client 1] who stated that he had been sexually and physically assaulted at the Just in Time Youth Services home. [...] A couple of days after the incident, [Staff #2] approached [Former client 1] again in his room. [Staff #2] began to take his hand and feel [Former client 1's] thigh. [Former client 1] stated that he was wearing pants that had a button on them, but that it did not actually button. [Staff #2] tried unbuttoning his pants, realized he did not need to, then slipped his hand down [Former client 1's] pants. [Staff #2] then began to fondle [Former client 1's] penis. -[Former client 1] could not give much detail about what exactly had occurred.
From the state's report. Deficiency cited, complaint survey. Cited: V 132. "[...]" 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.
[Former client 6] was hospitalized and sustained a "broken jaw a deep gash over her eye as well as an injury to the back of her head." Review on 5/2/23 of police report revealed: [...] "[Sheriff Deputy] was never dispatched to disturbance here. [...] Three staff (she, staff #3 and [Former staff 8]) were working at the sister facility A when [Former client 6] was hit by the car. [...] The fourth staff member who should have been working was at the store when [Former client 6] was hit by a car.
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Based on the documentary evidence, interviews, and statements obtained during the investigation process, LPA was able to corroborate the allegations, Staff member handled minor in a rough manner and Staff member used inappropriate language toward minor. Although Client #1 threw the remote control at the television because staff threw away [Child 1]'s cereal, confidential interviews, consistent statements, and documentary evidence revealed [Staff 1] grabbed [Child 1] by their neck and pushed [Child 1] to the floor.
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.
A caregiver used an inappropriate technique on a child which caused him to the be thrown on the ground with excessive force.
A 15 year old child in care was provoked to engage in a physical altercation with a staff person where the child was slammed to the ground and held in an inappropriate hold.
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; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
During the investigation it was found that a staff member used excessive physical force and slapped a child in care, putting them at risk for physical injury.
During the investigation it was found that a staff member hit a child in care on the back of the head.
During the investigation it was found that a staff member improperly restrained a child in care by holding the child around the neck with the child's hands behind their back
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.; 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway.
In an investigation conducted by DFPS, two staff were found reason to believe for physical abuse of a child.
Staff was observed via the EBI video, using excessive force when he lifted the child off of the ground during a restraint, causing the child's feet to drag; consequently, causing both child and staff to fall to the ground and injuring the child's foot.
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; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
It was determined through interviews that a staff member did push a child, making the child fall and hit their head.
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.
Both clients who had assaultive incidents with [Staff 1] confirmed the [Staff 1] had assaulted each of them on separate occasions.
From the state's report. Substantiated. Cited: 86172(b)(2). 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 staff member pushed a child onto a bed and punched the child in the face, leaving a mark and causing pain. Police came to the home after the child texted a friend about another staff member. Our summary of the state's report. The state's own wording follows.
Client #2 eloped from the facility. [...] He had eloped from the facility about 3 times. [...] Staff #1 had pushed him to the bed and punched him in the face a couple months ago. Law Enforcement (LE) responded to the home after he texted a friend about staff #6. [...] Staff #1 stated "you want to kick the wall." Client #1 said "why are you hurting me?" Staff #1 said “you ain't got no money you ain't going to do no Property damage, You ain't kicking no doors and walls. [...] Staff #1 pushed him to the bed and “punched” him in the face once [...] He had a mark on the right side of his face from being punched by staff #1. He was in pain for about 2 days after he was punched by staff #1. [...] Staff #1 "pushed" client #1 onto the bed. [...] There was an allegation a staff hit a client in the jaw. [...] The CPS worker said the allegation was a 40 year old male, who she identified as staff #1, had body slammed client #1.
From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 366] 27G .0603 Incident Response Requirments V 366 | |. "[...]" marks text left out between sentences.
On March 24, 2022, Community Care Licensing received information alleging that Staff #1 (see LIC811 dated 03/14/2023) pushed minor #2 (see LIC811 dated 03/14/2023) while in care. Confidential interviews with two staff revealed that the minor was pushed by the staff while multiple witnesses were present. [...] Confidential interviews confirm that the staff member #S1 did push the minor in care. [...] Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegation that the staff #1 pushed the minor #2 while in care is substantiated.
From the state's report. Substantiated. Cited: 87072(c). "[...]" marks text left out between sentences.
A staff member hit 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.
Individual #1 was physically assaulted a second time on 9/22/19 and during that assault there was again only one staff member present with the group of individuals.
The provider failed to report a Level II serious incident involving individual #1 which occurred 9/22/19 in which the individual was physically assaulted. [...] After Individual #1 is physically assaulted, the provider suggests, and offers to put into place, a corrective safety protocol. [...] Another Level II serious incident occurred on 9/22/19 in which Individual #1 was physically assaulted a second time and during that assault there was again only one staff member present with the group patients.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-105-150. (5) The provider including its employees, contractors, students, and volunteers shall comply with: 5. The provider's own policies. All ...; 12VAC35-105-160. D. (2) The provider shall collect, maintain, and report or make available to the department the following information: 2. Level II and Level .... "[...]" marks text left out between sentences.
Based on confidential interviews by (IB), ([Staff 1]) (see LIC 811 confidential names dated 9-27-22) sexually assaulted ([Child 3]) on three separate occasions, that occurred in a location outside of the facility. Based on the information obtained, there is a preponderance of the evidence to prove that staff had a sexual relationship with a foster child.
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.
During the investigation it was determined that children were subjected to corporal punishment when staff members pulled them by their arms.
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.
Assessment dated 1-6-23 revealed: escalating aggression...3 hospitalizations since 922- 22...attacked his grandparents...attacked school officer. [...] The Maintenance Director reported that he saw Staff #1 yelling, kicking, grabbing Client #3 around the neck and slamming him against the bathroom wall. [...] Phone interview on 1-27-23 with Client #3 revealed: "He (Staff #1) slammed my head into the wall and it hurt me.”
Stated that Staff #1 had grabbed him around his neck and threw him against the wall. [...] Staff #1 grabbed Client #3 by the throat from the front with one hand and slammed him into the wall. This was in Client #3's bathroom and it broke the sheetrock in the bathroom when Staff #1 slammed Client #3's head against the wall.
From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512 Vv 512; V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.
([Child 1]) was upset with ([Staff 1]) and threatened ([Staff 1]) and started hitting the staff member, which resulted in ([Staff 1]) stabbing ([Child 1]) in the left abdomen. The facility contacted the authorities, and ([Child 1]) was transported to the hospital by ambulance.
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.
Video camera footage, captured by the facility, showed a staff using her forearm to push a child back into his room, forcing him to comply to directives for quiet, calm down time.
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.
It was also reported that [Staff 1] pushed [Child 1] against the wall during the incident out of anger. Confidential witness statements revealed that [Staff 1] did push [Child 1] against the wall. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met regarding the allegation that [Staff 1] pushed [Child 1] while in care, therefore the allegation is found to be substantiated.
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.
On 8/31/ 21, CCLD received an allegation reporting that on 08/29/21, [Staff 1] physically restrained [Child 1] causing injuries to [Child 1]'s neck area and possible rib fracture. Licensing Program Analyst (LPA), Regina Martin investigated the complaint allegation and based on information obtained, the preponderance of the evidence standard has been met, the allegation of physical abuse was substantiated.
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.
During the course of the investigation this standard was found to be deficient when a caregiver threatened to physically harm a child in care and pulled him by his hoodie.
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.
In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.
From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.
A staff member pushed a child against a wall as a form of discipline.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
A caregiver restrained a child by dragging him by his feet while another staff member grabbed his arms immediately after the child had fallen several feet onto a hard floor.
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.
Once on the ground [Staff 1] is on top position restraining [Child 1], [Staff 1] places his left arm around [Child 1]'s neck in a choke hold position and restrains [Child 1] from moving for a few seconds. [...] [Staff 1] releases [Child 1], walks a few steps backwards, [Child 1] gets up and walks towards [Staff 1], [Staff 1] punches [Child 1] in the face with his right hand with a closed fist.
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.
[Staff 3] contacted non-emergency numbers and Oxnard Police Department. [...] At 6:30pm Oxnard Police Department arrived and detained minor [Child 1]. Oxnard Police Department notified [Staff 2], [Staff 3] that [Child 1] would be placed on a 72-hr hold/5150 at St. John's Regional Medical Center stating he was threatening the staff, children and destroying property. Based on witness, and video footage [Staff 2] conducted inappropriate restrain hold to [Child 1] to prevent from harming himself and others.
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.
Staff member stated during interview they did push victim prior to restraint and did not accept the apology victim offered them. Two children confirmed staff member pushed victim to the floor.
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.
Confidential interviews, documentary evidence of Special Incident Report (SIR) 788640, and LPA review of video footage of the incident revealed that cleint was improperly restrained and placed in a choke hold..
From the state's report. Substantiated.
LPA confirmed through confidential interviews and incident reports that a staff person engaged in intentional physical contact with youth by pushing or hitting youth with a laptop computer. [...] Title 22 deficiencies were cited regarding the physical abuse.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
The preponderance of evidence standard has been met, therefore the allegation [Staff 1] pushed [Child 1] is found to be Substantiated.
From the state's report. Substantiated. Cited: 87072(d)(10). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Based on confidential interviews and record review, the preponderance of evidence standard has been met, and the allegations that staff ([Staff 2]) hit minor ([Child 1]) while in care and staff ([Staff 2]) is engaging in inappropriate behavior are substantiated.
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.
Although the youth in the complaint is unable to corroborate the allegation, five interviews do corroborate that a minor was hit by staff while in care at the facility.
From the state's report. Substantiated.
Employee #1 continued to utilize excessive force, causing injury to Resident #1 before a three-person proper restraint was implemented.
Resident #1 was improperly restrained and remained in the care of Employee #1 in lieu of following their plan examples of "What helps me calm down or stay calm" and "What can staff do to help me" as outlined in their behavior support plan.
Employee #2 and Employee #3 arrived in the common area and witnessed Resident #1 being held down in an unapproved restraint.
Employee #1 was seen through video camera footage delivering several excessive and improper restraints towards Individual #1. Employee #1 is seen at one time pushing Individual #1's head into the door during a hold. [...] Use of excessive force when placing a person in physical or mechanical restraint; This regulation was NOT MET as evidenced by: Per the review of video camera footage by the Office of Human Rights Advocate and Office of Licensing Specialist #2 and Employee #3 watched Employee #1 place Individual #1 in an incorrect restraint without intervening.
A review of video footage on 7-25-22 for an incident occurring on 7-21-22 showed that Employee #1 used excessive force during an inappropriate physical altercation with Resident #1. Video footage reviewed on 7-25-22 confirmed that Employee #1 physically assaulted Resident #1 on 7-21-22. Video footage showed that Employee #2 and Employee #3 did not intervene appropriately when they witnessed Employee #1 holding Resident #1 in an inappropriate restraint. Employee #2 and Employee #3 walked around Employee #1 holding Resident #1 in an inappropriate restraint.
From the state's report. Non-compliance, DBHDS investigation; Non-compliance, systemic, DBHDS investigation; Non-compliance, systemic, DBHDS inve. Cited: 12VAC35-46-625. A. (7) The provider shall have and implement written policies and procedures for the on- site provision of a structured program of care or ...; 12VAC35-46-900. A. (3) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;; 12VAC35-115-50. B. (2) In receiving all. "[...]" marks text left out between sentences.
While the interviews had inconsistencies, video camera footage indicated the staff member did grab the arm of a client with unnecessary force.
From the state's report. Substantiated. Cited: 84072(d)(11).
A child was inappropriately restrained.
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.
It was also confirmed that staff slapped client in the face. Based on LPA's interview with Administrator and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Staff inappropriately restrained a minor while in care and Staff slapped a minor while in care is found to be SUBSTANTIATED.
From the state's report. Substantiated. Cited: 80072(a)(3), 87095(a)(1)(5).
During the course of the investigation, it was determined a child in care was physically abused by a caregiver when he was choked.
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 facility is found in violation of this rule as both staff and youth witnesses saw Staff 1 push Youth A.
From the state's report. Violation established, special investigation. Cited: R 400.4158 Intervention standards and prohibitions.
Staff engaged in physical discipline by slamming child on a table due to child refusing to follow instructions.
Staff member slammed child on a table during the incident.
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.
In plain words: A former client reported to a school counselor that the chief executive officer was too rough during a physical hold. The report stated this caused bruises on the arms and legs and pain in the head and buttocks. Our summary of the state's report. The state's own wording follows.
An investigation had been completed this month (July 2022) regarding a client (former client (FC) #2) who made an allegation that the Chief Executive Officer/Qualified Professional (CEO/QP) physically abused him; [Former client 2] had reported to his school counselor (5/27/22) that the CEO/QP was too rough when he restrained him which resulted in bruises on his arms and legs and pain in his head and buttocks.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. 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.
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.