summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: The 2 first aid kits were evaluated and were missing thermometers, and gloves. 1 first aid kit was missing, scissors, and tweezers as well.

Correction Narrative:
An email was received with the Corrective Action Taken: New first aid kits will be purchased by 11/12/2025.
Preventive Measure: The House Manager will conduct monthly audits of all first aid kits using the new checklist. Documentation will be kept in the Safety Binder for review during licensing inspections.


state: TX

facility_name: Harmony Therapy and Treatment Center LLC

summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: There is no documentation of a severe weather drill since year 2023.

Category: Safety and Emergency Practices

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative:
An email was received with the Corrective Action Taken: A severe weather drill was conducted on November 6, 2025, and documented in the Emergency Drill Log.
Preventive Measure: Emergency drills (fire, severe weather, evacuation, and shelter-in-place) will be conducted according to DFPS timelines and documented in a Drill Calendar. The Administrator will review and initial monthly drill logs to verify compliance.


summary: 748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for

raw_content: A caregiver responsible for one to one supervision of a child failed to notice when the child walked away undetected during a group outing.

Category: Individual Standards Evaluated

Correction Narrative: On 8-7-25, the operation submitted their CAP for this citation. The operation has already retrained staff on one to one protocol. They provided verification of the training with staff signatures. The documents have been uploaded to Document Library.


summary: 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

raw_content: The name of several witnesses has not been recorded on the Serious Incident Report. According to interviews conducted during the investigation there were several witnesses to the incident.

Correction Narrative: On 8-7-25 the operation submitted their CAP. The operation will be conducting refresher training with staff regarding proper completion of their SIR reports.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: Caregivers failed to redirect children in their care from interfering during a behavioral incident involving another child. This resulted in a physical altercation between the children. Two children required medical attention.

Standard Risk Level: Medium High

Correction Narrative: On 8-7-25, the operation submitted their CAP for this citation. The operation will conduct training on group dynamics, redirection, de-escalation, Role play and coaching sessions. They will also increase floor supervision and disciplinary action.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: Active employee files reviewed have no record of a notarized Pre-Employment Affidavit for Applicants for Employment form.

Category: Personnel

Correction Narrative: Revised new hire checklist will now include all DFPS-required forms and a signature block confirming notarizations. All hiring documentation will be verified by the Administrator before the new hire is scheduled for training or placed on duty. All new hires must submit their notarized forms before their first day of work. All supervisory staff will complete a personnel compliance refresher by June 10, 2025. The refresher will include review of standards 748.363, 748.505 and 748.753 and documentation procedures


summary: 748.363(10) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: Active employee files reviewed have no record of acknowledgement of reporting suspected child abuse, neglect, or exploitation policies.

Category: Reports and Record Keeping


summary: 748.363(9) - Personnel records - Include a statement signed and dated by the employee that he has read a copy of the operational policies.

raw_content: Active employee files reviewed have no record of acknowledgement of operational policies.

Correction Narrative: Revised new hire checklist will now include all DFPS-required forms and a signature block confirming notarizations. All hiring documentation will be verified by the Administrator before the new hire is scheduled for training or placed on duty. All new hires must submit their notarized forms before their first day of work. All supervisory staff will complete a personnel compliance refresher by June 10, 2025. The refresher will include review of standards 748.363, 748.505 and 748.753 and documentation procedures.


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: Multiple active employee files reviewed have no record of 	Pre-Employment Screenings.


summary: 748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: An active employee record has an unnotarized Licensing Affidavit for Applicants for Employment form.


raw_content: A staff member attempting to retrieve a cell phone from a child in care that led to a physical altercation that could have been avoided.

Standard Number / Description: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

Correction Narrative:
The incident was reviewed by the administrative team to identify breakdowns in judgement and procedural adherence. The affected child received therapeutic follow-up, and a safety debrief to ensure emotional and physical well-being. The incident was documented submitted to licensing and the child's caseworker as required.

All direct care staff will participate in a mandatory refresher training within the next 30 days. Trauma Informed Behavior Management.
All staff will receive a written reminder of their responsibilities under 748.507(1). The employee code of conduct and behavior intervention protocols will be re-reviewed at the next staff meeting. Harmony will ensure continued compliance with all minimum standards, administrative rules, DFPS statues through monthly audits and incident reports.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: A caregiver did not intervene until an injury occurred.

Standard Risk Level: High

Correction Narrative: Received a corrective action plan from the facilities administrator stating the following: The administrator reviewed the standard numbers 748.685(a)(4), 748.1531(a)(2). The administrator will ensure that all minimum standards are followed evidenced by making sure all appointments will be scheduled and attended as appointed. The administrator discussed with staff the importance of providing the level of supervision necessary to ensure all children are safe.


summary: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain

raw_content: A child in care involved had a fractured hand. A follow-up was needed but the child did not attend his follow up appointment.


summary: 748.3231(b) - Evacuation-In an emergency, move all children to designated safe area known to employees, caregivers, & volunteers

raw_content: The operation did not timely inform Licensing, caseworkers of the temporary change of address due to inclement weather.

Correction Narrative: A corrective action plan from the administrator of the facility stating the following:  The administrator reviewed the standard number 748.3231(b). The administrator will ensure that all minimum standards are followed evidenced by making sure all parties are aware of the evacuation including, pertinent information such as location, staff census, and any other contact information that is requested.


raw_content: A child in care admitted that himself and two other residents were able to AWOL from the facility without staff noticing it.

Standard Number / Description: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

Correction Narrative: Interviews were conducted with two youth in care to discuss supervision. No concerns were noted.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: During the inspection, it was observed that all three fire extinguishers were not in compliance; only one had a tag with the last inspection identified as April 2023.

Correction Narrative: Administrator acknowledged that the operation would ensure that the fire inspection is updated once every 12 months from the last fire inspection. A copy of the label was emailed.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: The operation failed to inform Licensing about the absence of an Administrator for a certain period and did not designate operational staff for emergencies.

Correction Narrative: Administrator stated that daily supervision and on-site administrative responsibility for the overall operation.


summary: 748.399(b) - Records Available for Licensing - reasonable access to storage and file areas

raw_content: The operation was unable to provide licensing with the requested documents upon request.

Correction Narrative: Administrator acknowledged that the operation would ensure that records are available for Licensing - reasonable access to storage and file areas.


raw_content: Operation failed to provide staff with key access to records/ documents upon Licensing's request.

Standard Number / Description: 748.399(b) - Records Available for Licensing - reasonable access to storage and file areas

Correction Narrative: The Administrator will ensure that all minimum standards will be in compliance, and all records will be made available upon request. The administrator will also inform licensing of any extended time off. A backup Admin was hired in June 2024.


summary: 748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle

raw_content: Operation vehicles did not have the required insurance verification.

Category: Transportation

Standard Risk Level: Low

Correction Narrative: The Administrator will ensure that all minimum standards will be in compliance, and all records will be made available upon request. The administrator will also inform licensing of any extended time off. A backup Admin was hired in June 2024. Photocopies of current insurance policies were submitted via email.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: Recreational calendar observed did not have the required indoor and outdoor options.

Category: Recreation Activities

Standard Risk Level: Medium Low

Correction Narrative: The Administrator will ensure that all minimum standards will be in compliance, and all records will be made available upon request. The administrator will also inform licensing of any extended time off. A backup Admin was hired in June 2024. A copy of the current updated recreational calendar reflecting indoor and outdoor activities was submitted for review.


raw_content: Fire Extinguishers observed were not current. The last inspection was conduct in May of 2023.

Standard Number / Description: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

Correction Narrative: The Administrator will ensure that all minimum standards will be in compliance, and all records will be made available upon request. All fire extinguishers were retagged and reflect the latest inspection and maintenance dates.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: An operation vehicle did not have a current state required registration. Documentation of registration could not be provided upon request.

Correction Narrative: The Administrator will ensure that all minimum standards will be in compliance, and all records will be made available upon request. The administrator will also inform licensing of any extended time off.


raw_content: The operation did not inform Licensing of their administrator's absence, the length of absence or identify a designated staff in the event of an emergency.

Standard Number / Description: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation


summary: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

raw_content: A caregiver yelled at a child in care.

Deficiency Narrative: A caregiver yelled at a child in care.

Correction Narrative:
The operation's administrator reviewed minimum standard 748.507(1),748.2307(8) and 748.2463(3) with staff. The administrator spoke with operation and will retrain staff on these minimum standards and reiterate to all staff the importance of these standards and ensure the health, safety, and well-being of the children.

On 7/1/24 the administrator completed a training with staff, the sign in sheet was provided.


summary: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

raw_content: An employee grabbed a child by the wrist.

Correction Narrative:
The operation's administrator will review minimum standard 748.507(1),748.2307(8) and 748.2463(3) with staff. The administrator spoke with operation and will retrain staff on these minimum standards and reiterate to all staff the importance of these standards and ensure the health, safety, and well-being of the children.

On 7/1/24 the administrator completed a training with staff, the sign in sheet was provided.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: A caregiver was using inappropriate language around children in care.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: There were several holes in the wall in the second floor bed room. All children's bedroom were missing window screens. The door on a dresser located in a first floor bedroom was broken and a nail exposed.

Correction Narrative:
A full walk through of the facility was conducted. Holes in the wall and window screens were replaced. Broken Dresser was discarded. Photos were taken and uploaded to document library.

The administrator reviewed this standard number 748.3351(1) with the staff and discussed the importance of reporting maintenance repairs. The administrator and manager will complete a daily walk through and document any needed repairs on a maintenance request and have them completed. The administrator will continue to train staff to ensure the health, safety, and well-being of the children and will continue to ensure adequate care and supervision.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.

raw_content: A child in care runaway on January 4, 2024. The incident was not reported to Licensing until January 7, 2024.

Correction Narrative: The administrator reviewed this standard number 748.303(a)(10)(A) with the staff and discussed the importance of reporting to Licensing in the scheduled time frame to ensure each child's safety and well-being. The administrator will continue to train staff to ensure the health, safety, and well-being of the children and will continue to ensure adequate care and supervision.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: A bedroom window was observed with blinds, shades, or other provisions.

Category: Physical Site

Correction Narrative: RCCR completed a full-walk through of the facility to assess and observe physical site changes.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: A broke door frame was observed, exposing nails.


raw_content: Three children in care made statements regarding staff being on their phones while supervising children. The investigator witnessed a staff member playing a game on her phone for 4-5 minutes while she was supposed to be providing one-on-one supervision.

Correction Narrative: The following corrective action plan was submitted via email by Administrator Marquese Clark. Standard number 748.685(a)(4) was reviewed with the staff and discussed the importance of adhering to the caregiver responsibility providing the level of supervision necessary to ensure each child's safety and well-being. Administrator will continue to train staff to ensure the health, safety, and well-being of the children and will continue to ensure adequate care and supervision. RCCR, Ashley Williams conducted an in-person follow-up at the facility on 11/29/2023.


summary: 748.983(a) - First-aid-CPR renewal-Each caregiver must complete any new first-aid training, as required to maintain a current certification

raw_content: The CPR/First Aid certificate for a staff's file reviewed expired 1/4/2023.

Category: Training and Professional Development

Correction Narrative: A Printable Wallet Card from the National CPR Foundation for Ophelia Brice was sent via email by Permit Holder Lily Woldu. Ms. Brice is certified is CPA/AED/First Aid until 5/16/2025.


summary: 745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving

raw_content:
A staff member with an active background check since December 2022 does not have a completed personnel binder on-site or a definitive start date.

A staff member who resigned two weeks ago is still listed as active in BGC.

Correction Narrative:
Correction: Background Check Validation 748.651(1)

Effective immediately, Executive Director Lily Woldu will conduct the background check validation every 90 days. Mrs. Woldu will set her calendar as a reminder to conduct the validation task.  Mrs. Woldu will conduct the next validation on 7/21/2023.

Mrs. Woldu will also be responsible to remove an inactive employee on the date the employee is no longer employed or within 7 days of leaving the operation.

Effective immediately, the operation's Quality Assurance Inspector, Willie Crumpton will be responsible to conduct personnel record audits every 30 days; or as frequent as the operation employs new hires. Upon hiring a new employee Mr. Crumpton will use the attached coversheet (with start date) as an audit tool for the personnel binders to ensure all the necessary documents are accurately filed.


summary: 748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.

raw_content: Bleach and Laundry detergent was observed in an unlocked pantry in the kitchen.

Corrected at Inspection: Yes


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: Deep freezer thermometer was observed at 60 degrees.


summary: 748.1221(c)(2) - Admission Assessment-Document why a delay in obtaining a piece of information is necessary, including efforts made to obtain the information

raw_content: The reason required information and due diligence to obtain it was not documented in the Admission Assessment.

Category: Admission, Service Planning, Discharge

Correction Narrative:
:  The operation created a checklist to ensure required documentation(s) and/or information is received during intake. If not received during intake, the operation will contact the managing conservator for such document via email.  Email proof will be placed in the child's record.  The case manager will be responsible to make diligent efforts at least 3 times during a 30-day calendar month to request the missing documentation(s) prior to completing the service plan. If unable to receive the requested documentation(s), the operation will document the email efforts in the client's record. If a phone call is made to the managing conservator for the requested documentation(s), the case manager will follow-up with an email to be added to the child's record.
Checklist observed with written correction.


summary: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

raw_content: Five of eight reviewed medication records to not document the reason the child's medication is prescribed.

Category: Medication

Correction Narrative:
11/23/22: Per the permit holder: Minimum Standards- Medication Records (Update Records) training is scheduled for 11/28/2022. Once completed on 11/28/2022, the operation will forward the certificate and attendance log to license. The administrator will be responsible to conduct daily quality check to ensure the medication logs are filled out correctly according to minimum standards.
12/16/22: training certificates received.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: Two medications for a child are not being administered according to the instructions on the bottle.

Correction Narrative:
11/23/22- Per the owner: Medication Administration (Instructions) training is scheduled for 11/28/2022. Once completed on 11/28/2022, the operation will forward the certificate and attendance log to license. The administrator will be responsible to conduct daily quality check to ensure the medication logs are filled out correctly according to minimum standards.
12/16/22: training certificates received.


summary: 748.2205(1) - Medication label error-Report medication label errors to the pharmacist

raw_content: A child's medication bottle contained an error, it states there were 60 pills prescribed when it was only 15. This was not addressed with the pharmacy.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: Three medication records for a child was observed without documentation of who administered the medication, the date or the time.


summary: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission

raw_content: Unauthorized Absence Log is missing required information.

Correction Narrative:
The operation created a new unauthorized absence annual summary log that include the name, age, gender, and date of admission. The administrator will be responsible to ensure the unauthorized absence annual summary log is completed with the child's name, age, gender, and date of admission.
AWOL log observed with corrections in compliance.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: Three children's binders did not document whether or not the child has allergies.

Correction Narrative: The operation corrected the deficiency on 11/16/2022 with a hand-written label to identify the known allergies and chronic condition. Going forward a pre-labeled sticky indicating known allergies and chronic condition will be added to the exterior of the binder. The case manager is responsible to place the pre-label sticky to the exterior of the binder during admission.  During admission, the case manager will be responsible to obtain the allergies/chronic conditions information from the managing conservator to be filled out on the pre-labeled.


summary: 745.4151(c)(5)(A) - Drug testing procedures-All drug testing will at a minimum screen for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP)

raw_content: Administrators drug test did not include testing for cocaine and phencyclidine (PCP).

Correction Narrative: Staff terminated; BGC inactive as of 9/8/22.


raw_content: The Unauthorized Absence Log does not include the child's DOA.

Standard Number / Description: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: There are inconsistencies in the operations policies regarding the services to be provided.


summary: 748.1101(b)(3)(J) - Children's rights-The right to personal space in the child's bedroom to store child's clothes and belongings

raw_content: Storage for children's clothing was not observed in all bedrooms at the time of inspection.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: Report to document EBI was not available for review at the time of inspection.


summary: 748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority

raw_content: Organization Chart does not depict all job titles for maintaining lines of authority.


summary: 748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge

raw_content: Discharge document was not available for review at the time of inspection.


summary: 748.3019(b) - Pest Control--Operation must use pest control operator licensed by TSPC Board or Dept. of Agriculture to prevent, control, eliminate pest infestations

raw_content: Pest control has not yet treated the operation.


summary: 748.101(2)(C) - Plans to submit - Fiscal plan - estimated 12 month budget

raw_content: Budget does not accurately depict necessary items.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: Daily recreational calendar was not available for review.


summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: Thermometer was not observed in the First Aid Kit.


summary: 748.109(2) - Admission Policies - include characteristics of the population the program serves

raw_content: Admission Policy does not accurately depict the population the operation will admit.


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: Drills document does not include length of time for the evacuation or relocation to take place.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: SIR does not include the operation's contact information or (8)Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: Shelter in place area was not observed on the Evacuation Diagram.


summary: 748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child

raw_content: Record to document EBI debriefing with a child was not available for review at the time of inspection.


facility_name: Shamar Hope Haven Residential Treatment Center

summary: 748.453(a)(5) - Unauthorized Absence - Annual summary log must include the intake report number, if report was made to CCR or DFPS

raw_content: The log provided did not include the intake report number, age, and gender of the child's unauthorized absence.

Correction Narrative: Operation sent its written correction via email. In its correction, the operation stated that the administrative team has met and all administrative office members received an in-service refresher training on what unauthorized absence log needs to include.


raw_content: The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate.

Standard Number / Description: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

Correction Narrative: Operation sent its written correction via email. In its correction, the operation stated that they have put in place a system for all records to be reviewed prior to filing into resident's file.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: The child medication log reviewed was observed prefilled of the amount given approximately 7 hours before evening administration.

Correction Narrative: The operation stated that they have started implementing new method regarding medication documentation. The administrator stated that they have started completing medication logs at the time medication is being administered to resident


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: A child in care sustained injury under his left eyes during physical altercation with another resident.

Correction Narrative: The administrator stated that moving forward that the operation will ensure that direct care staff places more emphasis on resident's conversations which may result to any physical altercation and staff will intervene immediately before the verbal altercation results to physical. She also stated that this will be communicated to all direct care staff during the next staff meetings.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done.

Correction Narrative: Follow up was completed at the facility. The administrator stated that she will be reviewing all hospital discharge paperwork and will schedule all follow up doctor's appointments moving forward.


summary: 748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible

raw_content: A child previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag.

Correction Narrative: The operation sent its written correction via email. In its correction, the operation stated that the program director or designee will contact CVS caseworker to bring additional bags at the time of discharge or pick up so trash bag will not be used. The operation also stated that it will be keeping extra bags at the facility in case CVS caseworker is not able to provide one timely.


summary: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

raw_content: The operation did not provide requested documents in a timely manner after multiple attempts.

Correction Narrative: The operation sent its written correction via email. In its correction, the operation stated that the Executive director will update the information on DFPS site to ensure they have both emails so the treatment team will have access to the emails so the request can be sent timely.


summary: 748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission

raw_content: The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child.

Correction Narrative: The operation submitted its written correction via email. In its correction, it stated that the treatment director and treatment team has an administrative review about this issue that the wrong paper was sent to the investigator. The operation will ensure that correct requested paperwork is always sent timely upon request.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: Multiple children in care stated that staff cuss at them.

Correction Narrative: Follow was completed by inspection at Shamar of Hope office. The administrator stated that training was conducted with all direct care staff and self-control, and prudent judgement was discussed during the training. Training was completed on July 11th and August 11th. Copy of the sign in sheet for the refresher training was provided to me and photo taken.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: Two children in care disclosed a staff member threatened residents.

Correction Narrative: The operation sent its written correction via email. In the correction, the operation stated that the treatment team met with the direct care staff on July 11th, 2025, to address the areas of concerns such as Trauma informed care, utilization of appropriate consequences and refresher course on crisis intervention training. Follow up by inspection was completed on 7-28-25 at the facility. Copy of the refresher training sign in sheet for training completed on July 11th, 2025, was viewed and photo taken.


summary: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

raw_content: During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files.


summary: 748.3441(n) - Food Preparation-Food must be protected from contamination

raw_content: During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter.

Correction Narrative: The operation sent its written correction via email. In the correction, the operation stated that management will speak with staff in B and C shift who are on duty during the day to ensure that breakfast foods such as cereals are properly closed after use and staff are not to leave the kitchen until everything is closed up before returning to another duty.


raw_content: During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25.

Standard Number / Description: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

Correction Narrative: The operation sent its correction via email. In its correction, the operation stated that they have appointed a particular staff to review files while the administrative assistant and another staff will look over the reviewed files.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: One open energy drink was found inside the fridge during the walkthrough of the kitchen


summary: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

raw_content: Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24  while the date of admission in the childrens list says 5-10-24.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content: During the walkthrough of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles.

Correction Narrative: Follow up was completed by Inspection at the facility. Sewer overflow problem was observed to have been fixed by the operation. Also, the operation sent its written correction. In the correction, she stated that the operation staff will make sure walkthrough are completed and repair man will be contacted immediately any issue is identified.


summary: 748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge

raw_content: During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24

Correction Narrative: The operation sent its written correction via email. In its correction, it stated that discharge plan will be provided within 15 days of discharge. Shamar Hope Program Director will ensure that each client receives a discharge summary.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24.

Correction Narrative: The Administrator stated that the operation will keep track of all licenses and permits and will make sure its renewed before the expiration date. She also stated that she has contacted the Fire Marshall regarding the fire inspection, and they will be installing 2 new doors by next week and the fire Marshall will be coming for the fire inspection October 11th. Copy of the new fire inspection issued on 10-10-24 was sent to me on 10-10-24.


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23.

Correction Narrative: The operation sent its correction. In the correction, it stated that executive director went over the form with office assistant to ensure she is checking on staff training due dates. Follow up by inspection will be completed later.


summary: 748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.

raw_content: It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22

Correction Narrative: The operation sent its correction. In the correction, it stated that executive director went over the form with office assistant to ensure she is checking on staff training due dates.


summary: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

raw_content: During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern.


summary: 748.363(13) - Personnel records - Include any documentation of the person's performance with the operation.

raw_content: During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file.

Correction Narrative: The operation sent its written correction. In its correction, it stated that executive director and office assistant will work together and continue to review staff files to ensure annual performance are completed timely. Follow up by inspection will be completed later.


summary: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.

raw_content: During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22.


summary: 748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.

raw_content: During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22


summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content: During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child.

Correction Narrative: The resident bed frame has been repaired by the operation.


raw_content: 2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection.


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area.

Correction Narrative: All physical site issues identified during inspection 4010304 was observed to be corrected during the inspection follow up.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: A staff member entered a child's room during sleeping hours and engaged in physical contact.  Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued.

Correction Narrative: The administrator sent the written correction via email. In its correction, she stated that all staff members were told anytime a client is awake in the bedrooms during sleeping hours and need to talk, staff is to call your coworker on duty so it will be two staff in the room to ensure your safety and the safety of a client at Shamar Hope Haven RTC. During the month of August the staff will not be added to the schedule. For the month of September, he will not be added to the schedule. I have decided for his safety that I will not allow him to return back to work at this time, he will be taken off the staff list. If you have any questions, feel free to contact us.


summary: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

raw_content: During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24.

Correction Narrative: The operation provided me with a copy of the child's completed initial service plan.


summary: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name

raw_content: During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician

Correction Narrative: Operation provided me with copy of the corrected medication log with name of the prescribing physician.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: During the review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection.

Correction Narrative: The operation provided me with a corrected medication log with proper dates, times, mane and signature of staff that administered the medication. Copy of the corrected med log was presented to me.


raw_content: During the walkthrough of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms.

Standard Number / Description: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

Correction Narrative: The operation has repaired all physical site issues identified. Walls, restroom roof and window blinds have been repaired and or replaced.


raw_content: During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22.

Standard Number / Description: 748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.

Correction Narrative: The operation provided me with copy of the staff psychotropic medication training certificate which was conducted after the citation.


summary: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

raw_content: During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director.


summary: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission

raw_content: The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL.

Correction Narrative: The operation sent its written correction via email on 3-22-24. In its correction, it stated that the program Director moving forward will assure all forms are made available when requested in a timely manner.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care.

Correction Narrative: 1 staff was interviewed, and he stated that refresher training on November the 10th with all direct care staff on how to intervene timely whenever residents are engaged in verbal altercation before it gets physical. The operation also provided me with written correction.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request.

Correction Narrative: Follow up was completed at the operation today. No scissors were observed in the children restroom and room.


summary: 748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions

raw_content: Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations.


summary: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity

raw_content: Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van.

Correction Narrative: 3 children were interviewed, and they confirmed there is always staff at the facility supervising them at all times. Operation management also held a meeting with staff to ensure that they are providing adequate supervision and always aware of children ongoing activity at the facility.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Children gained access to a bottle of hand sanitizer and were able to ingest it.

Correction Narrative: 3 children and 2 staff were interviewed and they stated that there has not been any hand sanitizer in the van since the hand sanitizer incident. Operations manager also had a meeting with staff advising them to ensure there is no sanitizer in the van and also kids must be supervised at all times when using hand sanitizer in the building and also advised staff to ensure they are providing adequate supervision of kids at all times.


raw_content: Staff used profanity while supervising kids at the facility.

Correction Narrative: Administrator sent the written correction via email. In the email, the Administrator stated that she and the Program Director will go over minimum standard that addresses prudent judgement, self-control while on duty and to ensure such incident which resulted to the citation does not occur again. These issues will be addressed during the next staff meeting on August 10th, 2023, according to her.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week.

Correction Narrative: The operation emailed me a copy of City of Houston Fire Inspection certificate for 2710 Truxillo with Approved comment in the Inspection report. Inspection was completed on 05-10-23.


summary: 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

raw_content: The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker.

Correction Narrative: The operation Administrator sent a written correction via email and stated that Shamar Hope Haven Program Director and caseworker will ensure that service plans letter of invite are sent to DFPS caseworkers timely for initial and review planning meetings.


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on January 31, 2023, it was determined that:

(1)    your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)    12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective January 31, 2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 8/1/2023.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL.

Correction Narrative:
An email was sent with an action plan to make sure they are in compliance.

*Uploaded in SharePoint*


summary: 748.535(2) - Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on July 29, 2022, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the failure of your operations administrator to ensure compliance include the following:

-	Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1)  Living Space and Physical Environment.

-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and

-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 07/29/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 01/30/2023.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content: Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: A child was restrained but the incident was not appropriately documented on the EBI Report.

Correction Narrative: Written corrections were submitted to CCR on 4/12/22. Operation conducted training on 4/11/22 with all staff. Signing sheet for the training was received.


summary: 748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free

raw_content: During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs.

Correction Narrative: Follow up to the citation was completed on 2-15-22. It was discovered that the operation has repaired the damaged wall inside the children room which resulted to the citation during HM inspection on 2-2-22. Photo of the repair was taken and will be uploaded in SharePoint.


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination.

Correction Narrative: Written corrections were submitted by the operation on 2/3/22. Administrator will review list closer to ensure no names are omitted. Background check was submitted.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: The van has only 8 operable seat belts out of a total of 14 seats.

Correction Narrative: Operation submitted written corrections on 2/3/22. Van was repair on 2/14/22. A follow up inspection was done on 3/3/22 during HM visit.


summary: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

raw_content: It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed.

Correction Narrative: Copy of the missing preliminary service plan from last HM inspection on 12-20-21 with signatures was provided to me during HM inspection today. Photo of the document was taken and will be uploaded.


summary: 748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides

raw_content: The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired.

Correction Narrative:
The facility provided the corrections to the investigator on November 11, 2021 showing that the van had passed the state inspection. Documents will be loaded into the system.

In addition, photos from the inspection dated 2/1/22 show the seats have been repaired and there were no lights on the dash when the vehicle was started.


raw_content: During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall.

Standard Number / Description: 748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free

Correction Narrative: During the follow up at the operation on 10-28-21, I observed all the issues identified in the narrative above has been corrected. Spoke with the administrator and she stated that the operation is going to ensure that all issues identified during the walkthrough is included in the walkthrough check list to avoid future citation.


summary: 748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof

raw_content: It was observed that a child in care did not have a matress protector on their bed.

Correction Narrative: Licensing rep, Carla McGowen completed a walk though of the facility. All beds had covers.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: According to the investigation, a child was placed in a supine position for more than 1 minute.

Correction Narrative: children were interviewed and no concerns were reported regarding restrains.


summary: 748.861(b)(1) - Pre-Service Training - Caregiver may not be solely responsible for a group of children

raw_content:
According to the investigation, a new staff was left
alone with children in care

Correction Narrative: Shamar Hope provided a statement regarding this citation. Shamar Hope stated: We will continue to do Pre -Service Training for all new hired caregivers and doing their first 40 hours of training they will observe but will not be allowed to be left along nor be responsible for a group of children. Once the staff has completed the 40 hours of observation a certificate will be file in their file.


summary: 748.863(a)(3) - Pre-Service Training-Caregiver for child-care or programmatic services only must have 8 hours EBI training, 4 pre-service & rest within 90 days

raw_content:
Based on the observation of the investigation,
two staff did not have their 8 hours of training
with their initial 90 days.

Correction Narrative: The corrective action plan states all case workers will receive their 8 hours of EBI training and 4 hours of pre-service & rest within 90 days while working with clients. The facility will make sure the training is in their file once completed within the time frame.


summary: 748.681(1)(B) - Caregiver qualifications-Must be at least 21 yrs old if all children in group are 13 yrs old or older

raw_content: According to the investigation, staff member was age 20 caring for children 13 years and older.

Correction Narrative: The operation provided a correction action plan stating no staff will be allowed to work at Shamar Hope Haven RTC unless they are 21 years effective 1/1/22 to avoid this citation in the future.


summary: 748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy

raw_content: Side 3  restroom was observed without a shower curtain during the walkthrough


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: It was observed during the walkthrough that there was no hand washing soap in side 3 restroom.


facility_name: ABH Texas Inc. DBA Devereux Texas Treatment Network

summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: Oncoming staff schedule to work was not notified of the incidents that occurred prior to his shift regarding the child in care he was supervising that was involved in a physical altercation with another child.

Correction Narrative: A corrective action email was received on 02/10/2026. In Summary it stated: The operation's procedures/protocol was reviewed with the alleged staff. Moving Forward Upper management staff will conduct random checks to ensure the procedures are being met.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: 2 of 4 child records reviewed didnt have the required dental exam scheduled within 30 days.

Correction Narrative: A corrective action was received via email from the operation staff on 10/28/2025, stating the operations manager will follow-up with the care coordinator to ensure dental exams are scheduled timely. An email notification from the dental office was received via email confirming the child dental exam is scheduled as of 10/29/2025.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Staff failed to separate two children and  remove toy bowling pins after a child was hit twice by another child before being injured after being hit a third time.

Correction Narrative: An inspection was conducted at the operation, the victims are nonverbal and observed.  The oject of aggression is no longer being kept on unit, confirmed during the walk-thru.


summary: 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

raw_content: It was reported that a caregiver restrained a child that wasn't acting out or being physically aggressive.

Correction Narrative: Inspection, observation of children, and interviews conducted in order to determine compliance. No concerns noted during the inspection, therefore this standard was determined to be compliance met.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content: Three Staff took three children on an outing, different from the one on the schedule, without getting prior supervisor's approval according to the operation's policy.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: It was reported that a caregiver used profane language to antagonize a special needs child.


summary: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

raw_content: This standard was found deficient as part of a DFPS Investigation.


raw_content: A caregiver wasn't made aware of filling a child's backpack with an extra pair of clothing.

Standard Number / Description: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers


summary: 748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute.

raw_content: The campus supervisor utilized a supine personal restraint on a child in care that exceeded the maximum length of 60 seconds.

Correction Narrative:
Unannounced follow up inspection conducted at the operation.  Interviews with children and staff conducted to determine compliance.
The staff member involved is no longer employed at the operation.
Additional training provided to current staff.


summary: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso

raw_content: A tenured campus supervisor utilized a supine restraint on a child, placing his knee on the child's stomach to hold the child down, while hitting and slamming his head on the ground.


summary: 748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being

raw_content: Although there were other staff on the unit, no staff came within range of the restraint to either monitor the restraint, monitor the child, or provide assistance to the supervisor performing the restraint.


raw_content: A tenured campus supervisor was observed on video utilizing inappropriate restraint techniques and physical force against a child resulting in multiple injuries to the child's face, wrist, torso, and back of head.

Standard Number / Description: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: An Autistic child with intellectual developmental disability was restrained by a tenured staff that was not an emergency situation.


summary: 748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being

raw_content: A staff did not do a thorough walk through when allowing a client to enter the restroom and two clients were able to act out inappropriately in the restroom with each other.

Correction Narrative: An email was sent to rccr on 09/28/2022 stating the following: The staff directly involved in the incident resigned the position as of 09/11/2022. Level of supervision and precautions monitoring will be discussed during the next staff meeting. The program director contacted rccr staff on 09/28/2022 and stated the staff in no longer with the operation and the operation will be requesting an administrative review for the citation.


summary: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: 3 out of 3 records reviewed were missing the required 6 month hours of EBI training.

Correction Narrative: Extension granted due until 07/01/2021 due to staff conducting an audit and conducting trainings within the operation. An email was sent to RCCR staff with a list of all employees that had their employee training file audited and corrected/conducted the required training. The email states moving forward the staff development manager will schedule multiple EBI course offerings every five months beginning in July 2021.


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: 1 of 3 staff records reviewed were missing the  required notary, job description, and education documents in the personnel file.

Correction Narrative: An email was sent to RCCR with a list of all employee files that were audited and corrected to reflect that all documents were obtained and placed in the operation's electronic file.


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: A direct care staff hired 01/25/2021 does not have the required initial background check. An employee hired on 10/12/2020 has an inactive background check.

Correction Narrative: BGCs reviewed, both active effective 4/13/21.-LG.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: 1 of 3 emergency intervention records reviewed showed that a child restrained on 04/08/2021 and the child was not debriefed until 04/12/2021 and the supervisor signed the form on 04/08/2021 but but the form wasn't actually completed until 04/12/2021. 1 of 3 emergency intervention records reviewed documentation dates were inaccurate.

Correction Narrative: An email was sent to rccr staff from upper management staff stating their was a training conducted to staff training the staff on properly filling out the ebi report and training the staff on seclusion room protocol. An inspection was conducted at the operation 04/27/2021 and the training documents were reviewed related to this training.


summary: 748.2553(4)(C) - EBI Release-Child released from seclusion no later than 5 minutes after the child begins exhibiting the required behaviors

raw_content: An EBI record reviewed showed that a child was held in seclusion for approximately 50  minutes after exhibiting the required behavior to end seclusion.

Category: Emergency Behavior Intervention


facility_name: Clear Vision Youth Center, LLC

summary: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

raw_content: First caregiver on scene conducted an improper restraint on a child in care that involved removing the child from a vehicle and slamming the child's face down to the ground, placing their weight on the child, then placing the child in a choke hold as the child was moved from the ground into the caregiver's vehicle. The second caregiver assisted while child was face down on the ground and did not intervene.

Correction Narrative: RCCR Inspector conducted a follow up inspection on 12/9/25. The inspector did a walk though of the operation with no physical site concerns. The director was interviewed about the compliance plan following the deficiencies. All staff were retrained in EBI and Crisis Prevention Intervention. The director is now a certified CPI instructor. The operation has an outside CPI instructor come once a month to conduct trainings while the director will conduct refreshers and give support to the concepts learned. Training certificates were reviewed. The operation has hired counselors and is focusing on hiring staff who have higher education and experience in working with children who require extra care.


summary: 748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used

raw_content: The staff member who was transporting the children didnt have a driver license in their possession and was unable to provide a copy to law enforcement.  The staff member was observed transporting other children from the facility when law enforcement arrived on the scene.

Correction Narrative:
On 12/02/2025, the operation submitted the following compliance plan.

Clear Vision now has an electronic charting system that we enter the expiration dates of Drivers licenses and other pertinent documents that expire.  The system will alert administration of documents that are approaching expiration and that are expired to prevent lapses in expired documents.

Electronic charting system usage and data entered by 12/01/2025.


Deficiency Narrative: This standard was found deficient as part of a DFPS Investigation.


summary: 745.4151(c)(5)(A) - Drug testing procedures-All drug testing will at a minimum screen for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP)

raw_content: During the review of drug screen of staff, it was observed that the drug screen did not include testing for PCP.

Correction Narrative:
On06/09/25, the operation administrator submitted the following compliance plan.

The operation requires staff will be drug tested through a lab (Concentra) during the onboarding process. In house drug tests for repeat screenings and random testing now are 12 panel tests and include marijuana, cocaine, opiates, amphetamines, and phencyclidine.  All staff that do not have the lab testing were tested in house with the 12 panel drug tests by a board-certified licensed family nurse practitioner. The operation includes the test results for all staff which has been uploaded to document library


summary: 748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered

raw_content: Child medication logs reviewed indicated the omission on specified time at which medication was given to the child. Signature on one record reviewed reflected no signature as to who dispensed the medication.

Correction Narrative:
On 06/09/25 Operation administrator submitted compliance plan.
Clear Vision noted that the children that receive twice per day medication, staff will omit am/pm on the medication logs. Administration added the AM/PM annotation that is pre-printed to the medication logs for meds given twice daily.

Updated documents per compliance plan have been updated to Document Library.


summary: 748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication

raw_content: Medication log on one of the records reviewed reflected no signature as to who dispensed the medication.

Correction Narrative: The medication log was corrected by the staff that did not annotate her signature. The designated staff (manager or lead) will be assigned to verify all signatures are documented on the medication records within 24 hours of administration.


summary: 748.103(b)(14) - Policies and procedures to submit - A suicide prevention, intervention, and postvention policy consistent with §748.124 of this division.

raw_content: Documentation of Suicide Prevention policy is incomplete.

Category: Organization and Administration

Correction Narrative:
On 06/09/25, the operation administrator submit the compliance plan.

The Operation's Policy was corrected to reflect the minimum standard and all required information in the agencies policy and procedures. Suicide policy has been uploaded to document library.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: During the review of serious incident reports, it was observed that the operation phone number was not included on the form.

Correction Narrative: On 06/09/25, operation administrator submitted compliance plan. The serious incident report was corrected and the phone number added to the paper document. Clear Vision uses electronic charting system as of 06/01/25 that has the facility demographics including, name address, and phone number pre-printed on the forms. A copy of the update serious incident report with the phone number has been uploaded into document library.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content:
Multiple seatbelts in the operation's vehicle are defective and unable to properly lock.

Although the operation has another vehicle available to transport, on 3/28/2025 Licensing witnessed the vehicle with the defective seatbelts being used to transport youth.

Correction Narrative: The lead will conduct a pre-trip safety check to include making sure that the seatbelts are adequately working prior to loading the van with youth. In the event the seatbelts are not functional, the staff will utilize one or both vehicles that have working seatbelts to ensure all youth are transported safely. Seatbelts were repaired on 04/02/2025. All vehicles have operable working seatbelts. Seatbelts were repaired on 04/02/2025. All vehicles have operable working seatbelts.


summary: 748.751(a)(2) - Pre-Employment Screening-You must contact the employer to verify if the applicant was employed as described in the applicant's employment history.

raw_content: Pre-employment contacts to employee's previous employers was observed to be missing from three of the four employee files reviewed.

Correction Narrative: Effective immediately, the LCCA will include the Pre-employment screening forms with the application and affidavit when an applicant interviews and is hired by the facility. The LCCA will file this screening form in the employee files behind the application.  The LCCA will check the employee binders on a monthly basis to ensure the pre-employment screening documents are being completed and filed.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: A child in care was struck three times with a shoe as a form of punishment.


summary: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

raw_content: A caregiver used excessive physical force by hitting a 9-year-old child with a shoe approximately three times.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: An employee failed to maintain self-control when disciplining a child in care.


raw_content: A potential staff was present and involved in an incident prior to the operation receiving the eligible background results. The incident occurred at the operation on 4/10/24 but the BGC results were not received until 4/12/24.

Standard Number / Description: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

Correction Narrative:
On 6/14/24 the following information was submitted via email from Krystal Williams, Administrator:
The LCCA will now complete all background checks before a potential applicant is allowed to be employed at Clear Vision Youth Center.  The LCCA has established a systematic approach to track and document the background check by using a spreadsheet with the applicant's name, date the background check was entered and the date of the results.  Once this information is completed then the applicant will be hired pending on the outcome of the background check.

A review of CLASS shows the background was completed on 4/12/24 for the staff involved in this report.
An in-person follow up was conducted on 06/24/2024, there were no current concerns with staff background checks.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: Children in care stated that an employee used profanity towards them as a form of discipline.

Correction Narrative:
It was stated during a follow up visit conducted with children in care that the alleged perpetrator no longer works at the facility, and no remaining staff use any profanity as a form of discipline.

The operation's Administrator emailed the following corrective action:
1.	Employee Atoya Eaden was taken off the schedule and ultimately terminated.
2.	Atoya Eaden was provided Non-Violent Crisis Intervention training and De-escalation techniques.
3.	Employees have been trained on the level system and we use a visible tracking board for the level system that employees use to take away stars as a form of discipline. Staff reward the youth based on the number of stars they have at the end of the week (allowance, extracurricular activities, and store trips to spend allowance).


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: It was observed in one of the four medication records reviewed that a daily medication administered on the morning of 11/20/2023 was not documented.


summary: 748.3001(b) - Sanitation Inspection-Each inspection must meet regulations of the local health department ordinances

raw_content: The health inspection is out of date for the operation which poses a safety concern for children in care.

Correction Narrative: The operation emailed a copy of their current Health Inspection.


summary: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

raw_content: One of the four files reviewed was not observed to have a completed Initial Service Plan for a child admitted on 07/07/2023.

Correction Narrative: The service plan meeting is scheduled for 8/28/23.  To ensure that service planning guidelines are met and completed within 45 days the administration team will set tentative dates upon admission, and have the reminder posted on our tracking board to ensure adherance to the 45 day deadline


summary: 748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign

raw_content: One of the four Service Plan's reviewed was observed to be missing a child's signature on a plan completed on 07/05/2023.

Correction Narrative: The resident has signed the service plan and upon the completion of the service plans the administrative team will ensure all service plan documents are signed within 48 hours.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: Three of the four files reviewed did not include suicide screenings in Admission Documentation.

Correction Narrative: The admission assessments were updated to include an initial Suicide screening assessment via the Columbia Suicide Severity Rating Scale.  Suicide screening will be completed on admission and included in the admission assessment, monthly, and as needed depending on the resident's presentation or at staff discretion.


summary: 748.1205(a)(2) - Admission Documentation-Includes court orders establishing who is the managing conservator for the child, if applicable

raw_content: Admissions documentation is missing: (a)(2) the managing conservator's address, (b)(6) Current dental status, including the available results of any medical and dental examinations, and (b)(7) Current substance abuse status.

Correction Narrative:
Corrections was made to the Admissions documentation showing the managing conservator address, the current dental status, including the available results of any medical and dental examinations and the current substance abuse status.
Updated mock Admissions Assessment was received and observed incompliance.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: The operation's Policy contains inaccurate information regarding a Case Manager, the ages of youth admitted, and job descriptions for the LCCA, Treatment Director, and PLSP.

Correction Narrative:
The Operation's Policy was corrected changing the case manager to the LCCA.  The ages of the youth were corrected to ages 5-12.  Corrections were made regarding the job descriptions for the LCCAA, Treatment Director, and the PLSP.
Updated job descriptions and policies were received and observed incompliance.


summary: 748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet

raw_content: Evacuation diagram does not include outside meeting place.

Correction Narrative:
The Evacuation diagram was corrected showing the meeting place outside will be across the street at the part.
Evacuation diagram was received and observed in compliance.


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: The Preliminary Service Plan does not address (b)(3) how the operation will meet the child's needs or (b)(5) who will be responsible for meeting each of the child's needs.

Correction Narrative:
The Preliminary Service Plan now addresses how the operation will meet the child's needs and shows who will be responsible for meeting each of the child's needs.
Updated mock Prelim Plan received and observed incompliance.


summary: 748.115 - Discipline policy - The discipline policies you develop for children in care must be consistent with Subchapter M of this chapter

raw_content: Submitted Discipline Policy does not address corporal punishment and other prohibited forms of punishment.

Correction Narrative:
The Discipline Policy was corrected and now addresses corporal punishment and other prohibited forms of punishment.
Updated policy was received and observed incompliance.


summary: 748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge

raw_content: Discharge Summary not available for review at the time of inspection.

Correction Narrative:
A discharge summary is now available at the operation to provide to the next placement or caregiver within 15 days of discharge.
Discharge Summary was received and observed incompliance.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: SIR documentation missing (1) telephone number of the operation, (3) age of the child or children involved, and (8) Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions.

Correction Narrative:
The serious incident was corrected and now shows the operation telephone number, the age of the child and the interventions made during and after the incident such as medical interventions, contacts made and other follow-up actions.
Updated SIR was received and observed incompliance.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: The Recreational Calendar does not include daily indoor and outdoor activities.

Correction Narrative:
The Recreation Calendar now includes indoor and outdoor activities on a daily basis.
Mock Recreation Calendar was received and observed incompliance.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: Storage for refrigerated medications was not available for observation.

Correction Narrative:
A mini refrigerator was placed in the main office for storage to place refrigerated medications in.
Photos of the mini fridge was received and observed incompliance.


summary: 748.2151(c)(4) - Medication record - must include medication name, strength and dosage

raw_content: Medication Record does not include a space for (c)(4) dosage or (c)(7) child's refusal.

Correction Narrative:
The Medication Record was corrected and now shows a space for the dosage and a child's refusal.
Mock Medication log was received and observed incompliance.


facility_name: Moving Forward Treatment Center

summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: During the time of inspection there were 2 theromometers missing out of the 2 red first aid kits for transportation and upstairs living quarters.

Correction Narrative:
The operation came into compliance when the Administrator bought thermometers and placed them in each first aid kit that was missing thermometers.

Photos can be found in document library.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: During the time of inspection, the medication storage was observed to not have a secondary locking mechanism for the psychotropic medications. The medications are stored behind a locked closet door in a filing cabinet that does not lock.

Correction Narrative: The operation came into compliance by fixing the locking mechanism on the filing cabinet where Psychotropic medications are kept. Video was recorded and can be found in document library.


summary: 748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others

raw_content: Service plan did not include a plan to address the five high-risk behaviors documented

Correction Narrative: Operation provided child's service plan with the 5 updated High-risk behaviors by describing the behavior and plan.


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: Several serious incident reports did not mention what staff did to stop the kids from running from the operation.

Correction Narrative: An email was received from the administrator on 6/11/2024. The operation had a staff meeting on 6/11/2024. It was discussed that staff will document what they did to prevent and intervene during incidents as runaways and etc.  Each staff signed the memo. The memo can be found in the document library.


summary: 748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.

raw_content: Operation policy states that they will maintain records for 12. The length of time is not complete and is unknown.

Correction Narrative: The agency has a provided a copy of their updated policies and procedures to licensing with all of the required corrections. The policies have been reviewed and appear to meet compliance with minimum standards.


summary: 748.3311(1) - Physical Site-Children under 16 years old must not be permitted to operate a tractor

raw_content: This standard along with 748.3312 are not addressed in the operation's policies.


summary: 748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available

raw_content: This standard is missing from the operation's policy.


summary: 748.911(c)(2) - Each caregiver must be certified and able to respond to emergencies prior to being the only caregiver counted in ratio.

raw_content: The operation's policy does not state that an employee cannot be counted in the child/caregiver ration until they have obtained their first aid & CPR training.


summary: 748.121(5) - Abuse and neglect policy - Actions that the parent of a child who is a victim of abuse/neglect should take to obtain assistance & intervention

raw_content: This standard has not been addressed in the operation's policies.


summary: 748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.

raw_content: Teh operation's policy states that a child over the age of nine may be restrained up to one hour.


summary: 748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.

raw_content: This standard is not addressed in the operation's policies and procedures.

Correction Narrative: The agency has a provided a copy of their updated policies and procedures to licensing with all of the required corrections. These corrections were reviewed by a CCR Program Specialist and found to be compliant with minimum standards.


summary: 748.881(7) - General pre-service training curriculum-Includes normalcy

raw_content: The operation's policy does not include the preservice training requirements for normalcy.


summary: 748.2271(1) - Adopt and Implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by DSHS.

raw_content: The operation's policy do not address whether or not the use of unassigned epinephrine injectors are permitted.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: The operation's policy does not state that unproductive work is prohibited.

Category: Discipline and Punishment


summary: 748.3283(a)(1) - You must ensure there are no unsafe products at your operation unless product is an antique/collectible and is not used/accessible to any child.

raw_content: This standard is not addressed in the operation's policies.


summary: 748.2901(2)(A) - Triggered Reviews-Review if child is personally restrained 4 times within a 7-day period, unless otherwise ordered or recommended in advance

raw_content: The operation's policy does not fully address this standard. The policy is missing a triggered review must occur if a child is restrained more than 12 times in 30 days.


summary: 748.109(2) - Admission Policies - include characteristics of the population the program serves

raw_content: The operation will only provide services to female children in care but the policies states that male children to be included.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

Deficiency Narrative: This standard is not addressed in the operation's policies.


summary: 748.345(3) - Electronic records policies - Requirements for routine back-up of data

raw_content: The operation's policies does not address the requirements for backing up the data for electronic records.


summary: 748.121(4) - Abuse and neglect policy - Strategies for coordination between the operation and appropriate community organizations


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: The operation's policy is does not address this standard.

Category: Children's Rights


summary: 748.1101(b)(5)(B) - Child rights-participate in service plan within child's ability to manage info and have copy of plan Child 14 yo or older right to review/sign plan

raw_content: This operation's policy only addresses that a child may be provided with a copy of their service plan but does not address that a child may sign and review their service plan.


summary: 748.3361(d) - Bedroom Space-A child may not sleep in the same bed with an adult caregiver at any time


summary: 748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services

raw_content: The agency's policy does not address the full standard. There is no policy regarding a child's right to medical, dental, vision, and mental health care and developmental services that adequately meet the childs needs.


summary: 748.2501(5)(A) - Emergency Behavior Intervention Orders-Required for mechanical restraint

raw_content: The operation's policy states that mechanical restraints are not allowed but has policies on the use of mechanical restraints.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: The operation's policy does not meet fully this standard and is missing the information regarding ways a child may file a complaint or make a report.


summary: 748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest

raw_content:
The operation's policy states that the staff will open or read the child's incoming or outgoing mail, including electronic
mail. The operation also plans to have children conduct their phone calls on speakerphone in the presence of staff.