summary: 748.393(b)(1) - Active child record-Includes child's full name and another method of identifying the child, such as a client number

raw_content: The child's record provided was just identified with initials.

Correction Narrative:
The operation submitted the following:
All active child records now clearly display the childs full legal name and client identification number on the file exterior and within the record.

Ongoing Compliance
Admission checklist updated to require full identification prior to file activation.
Administrator review completed within 24 hours of admission.


state: TX

facility_name: Southall Heritage Youth Home

summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: During the inspection 2 personnel files reviewed did not have documentation of contact with the previous employers

Category: Personnel

Standard Risk Level: Medium Low

Corrected at Inspection: No

Correction Narrative:
On 4/15/26The operation emailed the following compliance plan:

- The operation will conduct regular personnel file audits to ensure pre-employment screening documentation is complete and maintained.
-This review is incorporated into the monthly audit process conducted on the first Monday of each month.
-A Pre-Employment Documentation Checklist is now required and must be completed prior to staff being placed on schedule.

Ongoing Monitoring:
- Any missing pre-employment documentation identified during the audits will be corrected immediately.
- The LCCA will verify completion and maintain audit records.


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: Information needed for the admission assessment was not documented in the child's file.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium

Correction Narrative:
The operation responded with the following:
Admission assessments are maintained in each childs record.
Ongoing Compliance
Admissions are not finalized until assessment completion.
Administrator or Designee sign-off required prior to placement confirmation.


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

raw_content: Several requests were made during the monitoring inspection for documents. The operation did not provide the documents that were requested.

Category: Reports and Record Keeping

Correction Narrative:
The operation responded with the following:
All records are now organized and readily accessible for licensing review.
Ongoing Compliance
Centralized licensing binder established.
Monthly inspection-readiness audits conducted.
Staff trained on document access during inspections.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: Employee files reviewed did not have documentation of contacts with the employee's references.

Correction Narrative:
All employee files now contain documented verification of previous employer contact, including employer name, date of contact, information obtained, and interviewer name.

Ongoing Compliance
Pre-employment verification checklist implemented.
Monthly personnel file audits conducted by the LCCA or designee.
Staff may not be placed on schedule until documentation is verified.


facility_name: Clairefontaine Care Center LLC

summary: 748.3397(d)(1) - Bathing-Provide showers and bathtubs with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: It was determined during the investigation inspection that the operation does not have running hot water due to non-payment of the gas bill,

Category: Individual Standards Evaluated

Standard Risk Level: Low

Correction Narrative:
Email received from the operation with Corrective action plan.
In response the operation indicated that the operation's gas account became inactive due to missed payment. The account had been set up on automatic payment, and the credit card on file had expired.
Corrective action: The outstanding bill was paid in full and service was restored on 3/9/2026.  The operation has updated the account with a current credit card and added secondary payment method. Plan will be that the administrator will review utility account statements monthly, a calendar reminder was established to monitor payments and utility service monitoring checklist will be maintained. The Facility Administrator will monitor utility accounts monthly and will keep documentation of payments and service status. Any interruption in utility services will be reported immediately and corrected without delay.


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: Medication logs for 4 youth were reviewed.  Log noted dates the medication was not administered as prescribed.

Standard Risk Level: Medium High

Correction Narrative:
Email from the operation with the corrective plan for the citation issued.
Resolution of the Issue: All medication administration practices were reviewed. The discrepancies identified were corrected immediately, and staff involved were re-educated on proper procedures.  Preventive measures:  check list and implementation of a real time documentation requirement immediately following medication administration.
Timeframes for compliance: Immediate corrective actions and staff retraining and competency validation completed by April 1.
Actions if Compliance is Not Met: Immediate removal of staff from medication administration duties.
Responsible Party:
Program Director and Medical Coordinator will ensure overall compliance.
Shift Supervisors will monitor adherence during each shift.
Quality Assurance personnel will conduct audits and report findings.


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: There was no medication log for over the counter medication.  Child indicated that he is given Benadryl for allergies.

Correction Narrative:
Email from the operation with corrective action plan for the citations that were issued.
Resolution of the issue-All current medication records were reviewed and updated and the missing entries were reconciled.
Preventive Measures-Implementation of a medication administration log, staff training conducted. Monthly internal audit will be conducted to ensure compliance.
Dates and timeframes:Immediate correction completed by 1st of April. Staff retraining completed by 1st of April. The operation will have daily logs checks and monthly audits. Action if compliance is not met Staff found non-compliant will receive immediate retraining and corrective counseling. Repeated non-compliance will result in progressive disciplinary action in accordance with HR policies.


facility_name: New Future Residential Treatment Center, LLC

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

raw_content: Licensing observed and photographed a cleaning chemical marked keep out of reach of children stored in an unsecured cabinet under the kitchen sink. Operation staff relocated the item to a locked closet.

Category: Physical Site

Corrected at Inspection: Yes


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: Licensing observed and photographed a broken piece of floor tile in the living room, which operation staff covered with tape to prevent a child in care from accessing the tile before a care giver could (hypothetically intervene) and prevent harm. The operation is in the process of replacing the tile.

Standard Risk Level: High

Correction Narrative:
04-22-2026. The assigned inspector staffed the compliance photos with RCCR management and it was agreed the photos can count as compliance since they are of the effected area.

04-15-2026. The operation emailed the assigned RCCR inspector photographs of the corrected floor tile area.


facility_name: The Origin Home for Children LLC

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

raw_content: A Child's Service Plan was not completed with in 45 days of the child's admission date.

Correction Narrative: The operation completed the service plan in question and updated operation policy. To ensure timely completion of child service plans, the operation will ensure service plans are completed 30 days after placement to allow 15 days for corrections, updates, and final completion on the 45th day.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: Food items were observed on the pantry floor.

Correction Narrative: The operation updated to policy to include, The Origin Home for Children LLC requires that all food items (perishable and non-perishable) are: Stored at least 6 inches off the floor; properly covered, sealed, or contained; and stored in designated, clean storage areas (pantry, refrigerator, freezer). The operation also completed also added that staff training specific to proper food storage and sanitation would be completed during onboarding and annually. Training includes DFPS Minimum Standards and food safety expectations.


facility_name: New Horizons Ranch Residential Treatment Center

summary: 748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan

raw_content: During the course of the investigation, it was determined that a preliminary service plan indicated that a child requires "constant supervision" due to self-harming behaviors. This plan was not followed when this child was left unattended for a couple of minutes giving this child an opportunity to run away with another resident.

Correction Narrative: A binder has been created for each of the houses that includes the service plans for each of the kids which includes supervision requirements for each of the kids placed in that house. This will allow each childs plan to be easily referenced for all staff working in the home.


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

raw_content: The basis for a child in care being restrained was for noncompliance and not an emergency situation or to administer medication.

Correction Narrative: Direct care staff have participated in training to review the reasons that an EBI can be initiated. Staff were provided with scenarios of situations which could lead to an EBI. Leadership staff discussed with direct care staff how restraints could be avoided in those situations and when EBI would be appropriate and when it would not be.


facility_name: The Jim H. Green Kidz Harbor dba Kidz Harbor

summary: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

raw_content: Staff pulled a child's ear as a form of discipline.


facility_name: Guardian Angels I Residential Treatment Center

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: Both service plans reviewed did not contain signatures nor reasoning for not having the resident sign their service plan.

Correction Narrative: Case managers will have each child sign their service plan when it is completed and then attach the signed copy to the service plan in our documentation system, Extended Reach. If the child does refuse to sign an incident report will be attached to the service plan in Extended Reach, describing why the service plan was not signed. Corrections to the files as made.


summary: 748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment

raw_content: Child's belongings/ clothing was taken away as a form discipline.


facility_name: LifeWorks Emergency Shelter

summary: 748.2311 - Discipline-person in care must not discipline or punish another person in care

raw_content: During the course of this investigation, it was disclosed that staff allowed multiple children in care restrain other children.

Correction Narrative:
As per the Administrator and Director, the operation recognizes the seriousness of youth placing multiple peers in hold during this incident and understanding the safety concerns this presents. As a result, the operation has implemented immediate intervention protocols for any youth who engage in physical altercations, including those involving restraining or holding another youth. The operation is currently implementing significant improvements to their schedules, procedures, and staff training to ensure all team members are well-equipped, supported, and prepared to respond effectively to critical incidents.
Multiple staff were interviewed at the operation who confirmed participating in refresher HWC training and that all staff were informed of the importance of following proper interventions during difficult circumstances involving children in care.


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

raw_content: It was disclosed that staff did not intervene during a physical altercation, citing lack of experience in managing such incidents and the absence of supervisory guidance to direct them appropriately.

Correction Narrative:
As per the Administrator and Director, the operation acknowledges that staff did not respond to the critical incident in a manner that ensured safety which resulted in a situation where a youth felt it was necessary to place another youth in a hold. In response, the operation is actively strengthening their staff training and onboarding processes. The operation has also implemented a revised staffing schedule designed to increase consistency, ensure all staff are full-time, and improve overall visibility and responsiveness to youth needs.
Multiple staff were interviewed at the operation who confirmed being informed that changes to their schedule would be made in order to have additional support and guidance by management.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: During the course of the investigation, it was found that several serious incidents were not reported to the A/N Hotline or were reported late according to minimum standards required timeframes.

Correction Narrative: The operation scheduled an installation date to update their security systems, prioritized training on proactive responses, and are in the process of organizing an all-staff training to review both current and new procedures. The operation is also discussing the idea of implementing an earlier curfew and updating policy on searches.


summary: 748.1113(b) - Child Rights searches-Search a child, his possessions, or his room only when reasonable suspicion exists

raw_content: It was reported that the operation was not doing adequate searches upon children returning to the operation from off campus and/or in the children's rooms when the operation already had suspicion and concerns regarding residents shoplifting/stealing, bringing, and using contraband such as alcohol/illegal substances and/or other items onto campus. It was reported searches were not documented by staff unless they actually found contraband.


facility_name: Kinship Konnection, LLC

summary: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents

raw_content: An open bag of sugar was observed in the kitchen cabinet.


facility_name: Amazing Touch Care Home

raw_content: Staff used an unsafe method to wake a resident by flipping their mattress, causing the resident to fall from the bed.

Standard Number / Description: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

Correction Narrative: RCCR conducted a follow-up at the operation on April 24, 2026, during which two staff and one child were interviewed. The child in care expressed no concerns with discipline and punishment nor his care or overall treatment at the operation. The child in care explained that the staff are good with redirecting the children and allowing them to calm down in their rooms. The child stated to have no overall concerns with the operation.  Two staff were interviewed and both stated that they were retrained on the EBI-Discipline policy and expressed that the incident that occurred was not taught nor is practiced at the operation. Staff expressed to not be present at the operation during the incident and mattress flipping is for the purposes of cleaning and sanitization. Neither staff expressed concerns with discipline and punishment. RCCR observed the operation to be following the safety plan that was implemented.


summary: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

raw_content: Staff put child's medication in a sippy cup and placed child on the school bus with medication still in the cup, not knowing if medication was consumed.

Correction Narrative: RCCR conducted a follow-up at the operation on April 24, 2026, during which two staff and one child were interviewed. The child in care confirmed that the staff members follow appropriate procedures when administering medication, and they check to make sure the children swallow their medication.  The child expressed to be unaware of any concerns regarding medication administration.  Of the two staff who were interviewed, one staff administers medication and confirmed that the staff were retrained on medication administration procedures, and there no current concerns regarding administration of medication. Staff explained the medication administration procedure and no concerns were noted. The second staff, who does not administer medication, also confirmed that the staff were retrained and there are no present concerns regarding medication administration. Action plan and training roster provided the Administrator were reviewed.


facility_name: Beacon Of Light Residential Treatment Center LLC

summary: 748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved

raw_content: Serious incident report does not identify the gender of the child in care.

Correction Narrative:
On 4/21/26, the operation provided the following compliance plan with DFPS Form 2991 attached.

Beacon of Light will use the DFPS form 2991 titled
Serious Incident report. Attached is the form.

Effective Immediately.


facility_name: Blessed Kidz Residential Treatment Center, LLC

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

raw_content: Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone. Additionally, the staff member did not demonstrate competency to perform the job duties as a staffing plan was enforced by the operation to separate that same child from the staff member.

Correction Narrative: On 3/27/25 an email was received by the administrator stating how the operation has implemented immediate staff retraining on professional boundaries, device use, and supervision expectations, including prohibition of personal device misuse. Additional supervision and device restrictions have been put in place to prevent unauthorized access to inappropriate content and ensure staff demonstrate appropriate judgment at all times.


summary: 748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation

raw_content: Interviews confirmed staff did not follow the safety plan implemented on a staff member.

Correction Narrative: On 3/27/26 the administrator sent an email stating they have hired a new administrator, and the Executive Director has retrained all administrators and staff on strict implementation of safety plans, with immediate supervisory oversight to ensure compliance at all times. A monitoring system with documented checks has been implemented to ensure staff identified in safety plans are not left alone with children.


summary: 745.8411(a) - Responsibilities - Not interfere with an inspection or investigation

raw_content: Interviews confirmed staff interfering with investigation by asking other staff members to remove any evidence off their phones.

Correction Narrative: On 3/27/26 an email was received from the administrator stating all staff have been re-trained on CCR requirements prohibiting interference with investigations, including preservation of all evidence. A zero-tolerance policy has been reinforced, with disciplinary action up to termination for any future violations.


facility_name: Youthful Haven

summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: During the inspection, I observed the EBI training certificates for two of two caregivers, and two of two employee files show the staff received 16 hours of EBI training in one day, and staff interviewed stated the training lasted 6 hours total.

Category: Training and Professional Development

Correction Narrative: On 4/23/26, the operation provided an EBI training certificate for the missing training indicating the staff received 16 hours of EBI training spread across two dates.  The plan also indicates the Supervisors/Administrative staff will review training status for all new employees prior to scheduling them.  The operation will also conduct monthly audits upon training records to correct any issues.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: During the inspection, I observed two of two caregiver records did not include instructor-led psychotropic medication training.

Correction Narrative: On 4/23/26, the operation provided training certificate documenting the staff in question received instructor-led psychotropic medication training delivered by an RN on 4/16/26.  The plan also states all required psychotropic medication trainings would be conducted as instructor-led, and monthly audits of training records will be conducted to ensure all time sensitive trainings are current.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: During the inspection, I observed one of four employee records lacked the Form 2912 affidavit.

Correction Narrative: On 4/23/26, the operation provided a completed 2912 for the identified employee record.  The plan also states the operation is implementing a pre-employment check list which will assist in ensuring the 2912 and other required documents are gathered and included in the files for all new hires.


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: During the inspection, I observed three of four staff records reviewed lacked completed employment history checks.

Correction Narrative: On 4/23/26, the operation provided completed employment history checks meeting the requirements for the files identified in the inspection.  The plan also indicates all hiring managers and administrative staff will be trained on pre-employment requirements, and a tracking checklist will be put into place to ensure the employment history for all prospective staff have been verified prior to hiring.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: During the inspection, I observed three of four employee records reviewed lacked completed reference checks.

Correction Narrative: On 4/23/26, the operation provided completed reference checks meeting the requirements for the files identified in the inspection.  The plan also indicates all hiring managers and administrative staff will be trained on pre-employment requirements, and a tracking checklist will be put into place to ensure all references have been checked.


summary: 748.913(a) - CPR Training- Must adhere to AHA guidelines & include curr. that incudes use of a CPR manikin & written & hands-on instruction/practice & testing

raw_content: During the inspection, I observed two of two caregivers files to lack acceptible CPR/First Aid training documentation.

Correction Narrative: On 4/23/26, the operation provided updated CPR/First Aid training for the identified employee records which meet minimum standards.  The plan also states the operation will only utilize certified instructors and will verify instructor credentials and course content prior to training.  Monthly audits of training records will be conducted, and renewal reminders issued at least 30-days prior to the expiration.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: The child was hospitalized 2/5, but the intake was received 2/7. The intake was called in late.

Correction Narrative: Operation staff drop off a serious incident report that is sufficient and up to standard for documents used at the operation.


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: During the investigation, staff members were let go, however their background checks were not inactivated under the operation's people list.

Correction Narrative: The operation deactivated all employees' portals who are no longer employed with the home.


facility_name: Peaceful Pathways Residential Treatment Center, LLC

raw_content: A child in care was transported to the hospital by EMS after being involved in a physical altercation. Neck pain and facial bruise were treated and medication was prescribed.

Standard Number / Description: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

Correction Narrative: Peaceful Pathways has appointed the LCCA to inform the Licensing within 24 hours of any injury or illness that requires treatment by a medical professional or hospitalization.


facility_name: Autistic Treatment Center

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: Residential Child Care Regulation observed and photogrpahed broken blinds, a broken wooden plank on a gate with a losse metal handle and a broken floor tile in a bathroom whish staff removed.


summary: 748.3561 - Protective Surfacing-Must install protective surfacing in all required use zones

raw_content: Residential Child Care Regulation observed and photographed a swing set at Tevern Oaks with no surfacing material.


summary: 748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child

raw_content: The operation has a folder with the information relevant to this standard, however, there's no one standard form which shows the parent/managing conservator received this information.

Correction Narrative: 07-22-2025. The assigned inspector emailed the operation administrators and requested a compliance response. The operation replied The Autism Treatment Center Professional Level Service Provider will ensure to provide the necessary ATC policies and information to the Parent of the Child at the time of placement.


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: The operation has much of the information needed for an admission assessment in different locations of children's files however there is no admission assessment.

Correction Narrative:
07-22-2025. The ATC Professional Level Service Provider will also sign and date the Admissions Assessment as well as ensure that this document remains in the child's record.
ATC Children's Services Coordinator, ATC Director will provide oversight and supervision.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: During a walkthrough of the facility, furniture was found to be in disrepair as a couch was observed with peeling faux-leather and a mattress observed with a permanent indentation, causing a dip in the mattress.

Correction Narrative: 09-08-2025. The operation submitted a compliance response:  "The Autism Treatment Center Departments (Facilities Manager, Case Management, Director, Residential Coordinator) worked together to replace the furniture in the Tavern Oaks home with new couches and new mattresses. Weekly walk-throughs will be completed by all departments including Administration to ensure that the home remains in good repair and is safe for the children. This includes continuing to address the paint in the home. ATC Facilities Manager has a multi-step project to address the peeling paint in the home. The project will entail placing paneling along the walls to shoulder height in order to prevent the children from being able to pick and peel the paint off of the sheetrock. The projected end date for this multi-phase project will be completed prior to November 15, 2025. An extension will be requested if more time is needed for the project."


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

raw_content: During a walkthrough inspection the walls in the bedrooms and bathrooms which children have routine access to were found to have been peeled and scratched off.


raw_content: Licensing observed and photographed lint built up behind the Tavern Oaks House electric dryer and a broken plastic shelf in the refreigerator at Waddesdon Bluff House.

Standard Number / Description: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair


summary: 748.930(a)(1) - Caregivers at operations with less than 25 children or 30% of their population receiving treatment services must have 20hrs annual training

raw_content: The operation did not provide the requested training records within the 10 day pending standard period.


summary: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication

raw_content: Residential Child Care Regulation conducted and onsite unannounced follow up inspection and while multiple staff confrm receving the refresher medication training, RCCR observed and photographed a prescribed medication left unattended in the refrigerator of Waddesdon Bluff House.


summary: 748.3301(e) - Physical Site-Outdoor areas must be well drained

raw_content: Residential Child Care Regulation observed and photographed a waist high container of standing water on the porch of Taven Oaks House.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: Licensing observed a package of ground beef left out in the kitchen sink, which felt warm enough to conclude it had been left out longer than necessary for cooking/thawing.


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

Correction Narrative: Residential Child Care Regulation interviewed three direct care staff who all confirmed receiving the supervision training in response to the citation.


Standard Number / Description: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication


raw_content: Staff did not conduct required bed check, and two children ran away from the home.

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


summary: 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards

raw_content: 07-17-2024. The assigned inspector conducted an on site unannounced follow up inspection and observed the operation to be clean and the bathrooms to be without standing water and there are new bathmats. The only hazard was wasps nests under the over hang at Tavern Oaks House.

Correction Narrative: 08-30-2024. The assigned inspector observed the operation with no insect nests and no other physical environment concerns and observed the operation's quarterly pest control from June 2024.


raw_content:
06-06-2024. The assigned inspector conducted an unannounced on site follow up inspection. The bathroom tile is Tavern Oaks still  has water on it because the edge of the shower has insufficient height to prevent water spreading to the floor during showers. A direct care staff cleaned the floor during the inspection. The hole in the Waddesdon Bluff bathroom wall is still there however the operation purchased a protective plate during the inspection. The operation has a meeting with a contractor on 06-18-2024 to repair paint chipping on the wall. The Tavern Oaks bathroom wall felt stronger and there was less of an odor in the bathroom. The inspector observed the outside areas of both houses clean with no brush. Air vents, tile and the kithcen cabinet were in compliance.

In Waddeson Bluff Home the tile in the restr4oom was broke in the restroom and needed to be repaired. The wall in the first restroom had a hole that needed to be patched up. One of the bedrooms in the home needed calking in the ceiling. One of the faceplates needed a cover on it. The front door needs to be replaced. The home at Tavern Oaks needs to have front door replaced. There are places in the home the paint is peeling from that needs to be repaired. Branches in the back needs to be properly disposed of. The tile in the kitchen needs to be replace on the counter and the floor where it is broken. The air vents in the home need to be cleaned. The drawer under the sink needs to be repaired.

Standard Number / Description: 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards


raw_content: In Waddeson Bluff Home the tile in the restr4oom was broke in the restroom and needed to be repaired. The wall in the first restroom had a hole that needed to be patched up. One of the bedrooms in the home needed calking in the ceiling. One of the faceplates needed a cover on it. The front door needs to be replaced. The home at Tavern Oaks needs to have front door replaced. There are places in the home the paint is peeling from that needs to be repaired. Branches in the back needs to be properly disposed of. The tile in the kitchen needs to be replace on the counter and the floor where it is broken. The air vents in the home need to be cleaned. The drawer under the sink needs to be repaired.


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

Correction Narrative:
06-06-2024. The assigned inspector observed both houses with no insect nests.

Residential Child Care Regulation observed and photographed a bee's nest  by the main entrance to Waddesdon Bluff.


summary: 748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications

Category: Safety and Emergency Practices

Correction Narrative:
06-06-2024. The assigned inspector observed the new staffing plan designating the lead staff to be responsible for these items during an evacuation.

The operation's emergency evacuation did not include the name of staff to secure essential personal items, such as medications in an emergency evacuation.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

Correction Narrative:
06-06-2024. The assigned inspector observed both houses'  pantry floors with no food and clean.

Residential Child Care Regulation observed and photographed food, including uncovered bananas stored on the pantry floor in Waddesdon Bluff.


summary: 748.3113(b) - Fire Extinguisher-Fire inspector must approve sprinkler system/fire extinguishers; if inspector not available, one 3A:40BC extinguisher required

Correction Narrative:
06-06-2024. The assigned inspector observed the fire extinguishers in both houses intact with tags OK.

Residential Child Care Regulation observed and photographed a fire extinguisher in Tavern Oaks House with tag ripped off.


raw_content: Residnetial Child Care Regulation observed and photographed a mop bucket with standing water on the deck outside Tavern Oaks House.

Standard Number / Description: 748.3301(e) - Physical Site-Outdoor areas must be well drained

Correction Narrative: Residnetial Child Care Regulation observed and photographed the outside areas of Waddesdon Bluff and Tavern Oaks houses with no concerns for standing water.


Standard Number / Description: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

Correction Narrative:
06-06-2024. The assigned inspector conducted an onsite inspection and observed no expired food or beverages in either Tavern Oaks of Waddesdon Bluff houses.

Residential Child Care Regulation observed and photographed expired milk jugs in the Tavern Oaks house.


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

raw_content: Bed in the bedroom in Waddeson Bluff did not have mattress on it.


Deficiency Narrative: In Waddeson Bluff Home the tile in the restr4oom was broke in the restroom and needed to be repaired. The wall in the first restroom had a hole that needed to be patched up. One of the bedrooms in the home needed calking in the ceiling. One of the faceplates needed a cover on it. The front door needs to be replaced. The home at Tavern Oaks needs to have front door replaced. There are places in the home the paint is peeling from that needs to be repaired. Branches in the back needs to be properly disposed of. The tile in the kitchen needs to be replace on the counter and the floor where it is broken. The air vents in the home need to be cleaned. The drawer under the sink needs to be repaired.


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: An administrative penalty will be recommended as a result of this citation, per HRC §42.078. Documentation reflects that medication was given outside of doctors orders.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: Medication errors were not documented for a controlled medication.

Correction Narrative:
On 05/07/2024, the operation provided the following corrective action plan: Psychotropic Medication administration and medication count will be documented on the child's Medication administration reports. Medications will be written according to the prescription label. House managers will review the documentation prior to turning the reports into the Nursing Department. Nursing staff and medical assistants will provide quality assurance and if there is an error or a correction needs to be made, ATC nursing department will notify the house managers and the residential coordinator for their review and follow up as well as provide direct care staff re-training as needed. Children Services coordinator (CSC) will provide additional quality assurance during supervisory visits and observations. CSC will assist with scheduling direct care staff training and re-training as needed for medication errors.

4/26/24, in person follow-up was completed at the operation and interview was completed with a caregiver regarding the medication logs and new processes. Also, staff admitted they were trained by the nurse. Interview with the nurse was completed. Although compliance date is still further out the operation was able to address the concerns.


raw_content: An administrative penalty will be recommended as a result of this citation, per HRC §42.078. Documentation reflects that medication was given outside of doctor's orders.

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


summary: 748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided

raw_content: Documentation for recreational & leisure activities nor activity calendar was available for review during the course of this investigation.

Correction Narrative: On 05/07/2024, the operation provided a copy of their recreation plan with a range of indoor and outdoor recreation leisure opportunities.


summary: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks

raw_content:
03-01-2024. The operation replied with a letter dated 06-09-2021 indicating annual testing is not required, however, did not provide documentation of any gas tests between 01-04-2021 and 01-04-2023.

Standard left pending. The operation has until 03/03/2024 to provide documentation of a gas leak inspection and gas service from no later than 01-04-2023.

Correction Narrative:
04-12-2024. The assigned inspector conducted an on site unannounced follow up inspection and verified the operation has a system in place to remind the house and grounds specialist to request inspections early enough in advance. The inspector verified this in a phone call to the specialist.

03-26-2024. The operation provided a copy of the gas inspection for Waddesdon Bluff house. Tavern Oaks house is electric.

03-25-2024. The assigned RCCR inspector requested a compliance response.


summary: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

raw_content:
03-01-2024. The operation provided confirmation documentation that they have a health inspection scheduled for 03-08-2024 but did not provide documentation of any health inspection completed between 11-28-2022 and 11-28-2023.

The standard is left pending and the operation has until 03-03-2024 to provide documentation that there was an annual health inspection prior to 11-28-2023.

Correction Narrative:
04-12-2024. The assigned inspector conducted an on site unannounced follow up inspection and verified the operation has a system in place to remind the house and grounds specialist to request inspections early enough in advance. The inspector verified this in a phone call to the specialist.

03-14-2024. The operation sent copies of the health inspections.


raw_content: Sanitation inspection was last conducted on 10/22/2021, a request to the city to conduct a new sanitation inspection was done on 11/16/2022. The sanitation inspection for both homes under the license have expired inspections, they were both due on 10/22/2022.

Standard Number / Description: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

Correction Narrative:
12/02/2022 Email from operation stated they will not be AR'ing this citation.
11/28/2022 Email received with new sanitation/health inspections for both Tavern Oaks and Waddesdon Bluff homes. Both inspections conducted on 11/28/2022 with no concerns noted.


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: Of the two homes, five restrooms total did not have hand towel, paper towels, or a hand dryer to assist with handwashing.

Correction Narrative: This standard is found in compliance after follow up was completed.


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

raw_content: Operation was aware of the incident involving a staff member who did not use appropriate judgement when supervising children in care and failed to report the incident to licensing or document in a serious incident report.

Correction Narrative:
On 10/03/22, compliance plan was received by operation through email.

The Autism Treatment Center will ensure to report any incident involving a staff member not using appropriate judgement when supervising children in care. These incidents will be reported to licensing as well as documented on a serious incident report.


raw_content: Licensing observed and photographed a broken plastic storage container on the back porch of Tavern Oaks house with broken plastic shards. Staff removed all broken plastic pieces.


summary: 748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.

raw_content: As of 07-19-2022 the data for restraints between January and March 2022 has not yet been reported to Licensing.

Correction Narrative:
08-12-2022. The operation submitted a compliance response: "The Autism Treatment Center will ensure to report restraint data to licensing quarterly because this data helps Licensing and the operation assess increases and decreases in restraints, effective behavior de-escalation and reduction of risk to children in care.
Access to the login information will be accessible from an additional computer so that if the PC is in technical difficulty, the secondary device will have the information to be able to login the appropriate site to enter the EBI restraints."

08-11-2022. The assigned inspector emailed the operation and requested a compliance.


summary: 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

raw_content: Licensing observed ratio at Tavern Oaks house to be one staff with six children in care.

Correction Narrative: 08-12-2022. The assigned inspector conducted an onsite unannounced follow up inspection and met with staff at both houses who indicated there was an in service meeting about ratio. Liceninsing observed ratio to be in compliance at both houses.  Licensing observed ratio to be in compliance at Tavern Oaks house to be one staff with six children in care.


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

raw_content: Licensing observed chemicals marked keep out of reach of children stored in an unlocked kitchen sink cabinet.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: Licensing observed two sour cream containers to be expired as of 06-06-2022 which staff removed.


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:
07-01-2022 The operation EBI training certificates showing the employee files reviewed in the inspection had some EBI training over the last 12 months, however not the required 4 hours every six months.

The standard is left pending and the operation has until 07-03-2022 to provide the training records.

Correction Narrative:
07-20-2022. I telephoned the operation training director. The operation now does a supplemental training for all staff to ensure staff are trained four hours every five months. The staff will have an EBI training certificate and a SAMA training certificate. The due dates will be monitored by a spread sheet.

07-19-2022. RCCR management approved follow up by phone and the assigned inspector left a message with operation manager in charge of training.

07-06-2022. The operation submitted a compliance response indicating they will ensure each employee who needs it will have four hours of emergency behavior intervention training and will retain copies of the certificates.


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 was found to be sleeping during the overnight shift without any other awake staff on shift.


summary: 748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly

raw_content: As of 04-22-2022 the data for restraints between January and March 2022 has not yet been reported to Licensing.

Correction Narrative:
05-12-2022. The operation submitted a compliance response indicating "Unfortunately there was an IT problem issue with the CPU that was the only computer with the login information saved in order to enter the quarterly restraint data for emergency behavior interventions. The reason the login information hasn't been downloaded to other computers is because it is still the old login user name for the previous ATC Director, (REDACTED -AP). Current ATC Director, (REDACTED -AP) has requested multiple times from DFPS to help change the login information to user name: (REDACTED -AP) but we have never been successful in achieving that with the help from the IT department associated with DFPS/HHSC.

Addressing the plan of corrections for the data not being entered for January  March 2022, the CPU with the login information has been fixed so that (REDACTED -AP) can enter the quarterly emergency behavior restraints to Licensing. The current login information has also been saved on a back-up laptop so that way if needed, that device can be used to enter the requested information within the allotted time frame required.

Can you please send the best contact for IT assistance associated with the HHSC website so that the user name can be changed to (REDACTED -AP)?

05-11-2022. The assigned inspector emailed the operation and requested a compliance response.


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

Correction Narrative:
Screws missing on screen in child's bedroom so screen was not secured on window. Bottom of door rotting.
Screens and bottom of door are now in good repair.


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

Correction Narrative:
Wires hanging in the boys closet, could pose potential hazard.
Wires have since been removed from closet.


summary: 748.1107(b)(1) - Child Rights parent contact-Document in the child's record any plans for contact between the child and a parent

raw_content: The facility did not meet required visitation rights between child in care and parent since December 2021.

Correction Narrative:
04-28-2022. The operation submitted a compliance response indicating "ATC will follow the court documentation regarding family members that have authorized visitation and not restrict or limit parent contact for the children placed with us through DFPS. ATC will continue to assist with transporting children to scheduled supervised visits. If the child is not feeling well or ill; if the parents are feeling well or ill, then ATC will honor the participation in a rescheduled visit. If transport is needed to a parent visit and ATC staff working with the child are unable to take them to the assigned location, then either the ATC house manager on-call; case manager; or residential coordinator will transport the child to the assigned parent visit."

04-26-2022. The assigned inspector replied to the 04-13-2022 email and asked the operation if this is their official compliance response. The operation replied and requested an extension until 05-06-2022. RCCR Unit 23 supervisor and the assigned inspector updated the new compliance due date as 05-06-2022 from the original 04-19-2022.

04-13-2022. The operation included the assigned inspector on an email to the child in care's CPS case worker asking how they can resume visitation.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: Operation staff indicated there a child in care had fractures which were not reported to the DFPS hotline.

Correction Narrative: 03-04-2022. The operation emailed a compliance response indicating they will continue to advise case managers and staff on the importance of timely reporting.


summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: The  medication count for a child in care was not documented correctly.

Correction Narrative: On 8/16/21, a compliance met was received via email from the administrator. The email stated.  Psychotropic Medication administration and medication count will be documented on the child's Medication administration reports. Medications will be written according to the prescription label. House managers will review the documentation prior to turning the reports into the Nursing Department. Nursing staff and medical assistants will provide quality assurance and if there is an error or a correction needs to be made, ATC nursing department will notify the house managers and the residential coordinator for their review and follow up as well as provide direct care staff re-training as needed. Children Services coordinator will provide additional quality assurance during supervisory visits and observations. CSC will assist with scheduling direct care staff training and re-training as needed.


summary: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

raw_content: On a medication log, the medication was not written according to the prescription label.


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: the registration inspection sticker on the vehicle at the Waddedson Bluff home expired 12/20

Category: Transportation

Correction Narrative:
Administration provided their compliance plan. On 6/14/21 ATC obtained the registration sticker for the Waddesdon Bluff van. Receipt from purchase attached. Admin (Maintenance Department, Residential Coordinator, Case Management, House Managers) will check vehicle maintenance monthly to ensure registration stickers are obtained within the proper timeframe. Provided a copy of the registration form for the van. TA was provided for physical site and the operation stated: June 2021 Maintenance log (attached) has the work orders for Waddesdon Bluff entered on 6/10/21. Maintenance staff are currently in the process of working on the repairs to the home (walls, ceiling, doors, furniture). At the end of each project completed, the maintenance log will be updated with the date completed and any additional notations. Patching holes in walls/doors is on-going & other larger projects such as the bathroom remodel will take more time. ATC is requesting the deadline for completion to be 7/14/21.

On 06/16/2021 I conducted an unannounced inspection and observed the registration sticker to be in compliance.


facility_name: L'Amor Village RTC

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

raw_content:
During a monitoring inspection, the following was observed:
-There was a window in the front room that was cracked on the inside and outside.
-One of the bathroom sinks had mildew and rotted sealant behind it. Note: this was corrected at inspection.
-One of the bathrooms had a mildew and rotted sealant behind a toilet. Note: this was corrected at inspection.


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

raw_content: Four childrens' records were reviewed during the monitoring inspection.One was missing child's signature on the orientation and grievance forms.


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:
The suicide prevention, intervention, and postvention policy is not consistent with the requirements of 748.124. The current policy in place does not:
-Address suicide prevention, intervention, and postvention;
-Include plans and procedures to support children who return to the operation following hospitalization for a mental health condition.
-Have approval from the Executive Commissioner of the Texas Health and Human Services Commission or Designee to use a suicide policy other than the model policy provided in the minimum standards.

Category: Organization and Administration


facility_name: San Marcos Treatment Center

raw_content: A child was able to enter the restroom and shower with another child. The staff did not see or know two children were in the shower together for duration of 12 minutes which is when checks are to be conducted by staff. One child admitted to seeing and touching of their private parts while in the shower.

Correction Narrative: Administrator stated that they completed additional training for the unit and that training on supervision will be refreshed campus wide. Administrator stated that weekly monitoring is also being conducted with the unit manager.


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

raw_content: During the review of the documents provided in this investigation there were several documents that were not filled out completely.

Correction Narrative: Administrator stated that each unit manager for reviewing documentation as needed which is normally twice a week. Staff interviewed stated that they are required to fill in every area of documentation and not leaving any areas blank. Upper management is also responsible for completing double checks of documentation.


facility_name: Azleway Valley View

summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: There were no menus in either house on campus. The operation has not been utilizing menus due to grocery changes every week.

Correction Narrative: On 3/10/2026 a site visit was conducted at the operation. Menus are posted on the front staff office window and visible. Photographs of posted menus were taken at both units. During this meeting, the Administrator identified the Quality Assurance Assistant will be responsible for organizing and posting the menu on each cottage.


facility_name: Journey to Dream - Kyle's Place

summary: 748.935(a)(1) - Annual Training Timeline-Each person must complete the required annual training within 12 months from the date of hire

raw_content: It was determined that a few staff members annual trainings were delinquent.

Correction Narrative: On 2/25/ 26, Operation provided implemented corrective action plan effective 2/10/2026, a comprehensive 365-day caregiver training and compliance management system. This structured process ensures that all caregivers are fully trained within the required timeline and remain in continuous compliance with all annual DFPS and Licensing training mandates. The operation also completed delinquent trainings on 2/10/2026, bringing the operation into compliance.


facility_name: Castillo Childrens Center

summary: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

raw_content: A service plan review was indicated as an initial plan instead of review, the PLSP, therapist and child's participation is not documented or dated.

Correction Narrative: Plan of correction received via email from Administrator detailed the following: Effective immediately, all service plans will contain all signatures of all participants no later than 7 days after the official date of the review. Also, the correct information regarding initial or review will be checked in the correct box. Service plans will be audited by the LCCA or designee on a random basis to ensure compliances. The plan of service related to this citation has been corrected and received.


raw_content: A subsequent service plan for a child did not adress skills for youth 13 and older.

Standard Number / Description: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

Correction Narrative: An email received on 02/13/26 from the administrator had the following plan of correction: Effective immediately all children 13 years of age and older will receive services for basic life skills development to include basic life skills training and the opportunity to practice those skills. These services will be documented in the child's plan of service for review.


summary: 748.3271(6) - First Aid Kits-Each one must be kept out of the reach of children

raw_content: Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.


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 December 19, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 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 the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on December 1, 2025, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025.
-	Operation failed to satisfy the conditions of the plan
-	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 plan.
An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

Correction Narrative: An HM extension was approved effective 12/19/25.  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 6/20/2026.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: A caregiver's Emergency Behavior Intervention training was not renewed timely.

Correction Narrative: An email received on 12/08/25 from the administrator with the following plan of correction: Effective immediately all staff will be scheduled to do the same training schedule. An alternate SAMA trainer will be located to provide the training in case of a scheduling conflict.


summary: 748.869(a)(3) - Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.

raw_content: The pre-service training records for one employee are not signed and dated by the instructor.

Correction Narrative: On 10/28/25, an email received from the administrator had the following corrective action plan: Effective immediately all pre-service training will have a certificate of completion, letter of completion or statement which is signed and dated to communicate the completion of said training. The LCCA will perform random personnel file checks to ensure this information is included, is accurate and is signed by the trainer. A copy of the corrected certificates were also received attached for the employee.


summary: 748.1337(b)(1)(A)(iii) - Initial Service Plan-Include intellectual functioning, including any testing and plans for recommended follow-up

raw_content: The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.

Correction Narrative: An email was received from the administrator with the following corrective action plan: Effective immediately information relating to a child will be consistent with in the common application, CANs Assessment, preliminary treatment plan and admission assessment. This will include any recommended testing or plans for follow-up assessments. The treatment director and the LCCA will be responsible for quality assurance of the initial plan of service and all referral documentation to ensure that all information is contained, individualized, and accurate across all documents.


summary: 748.4045 - Safety restraints-only one person may use each child passenger safety seat system or safety belt

raw_content: During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.

Correction Narrative: An interview with staff on 09/23/25, staff was aware each child needed an individual safety belt.


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: During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.

Correction Narrative: An interview and observation conducted on follow up inspection completed 09/23/25 staff was aware of children in need of safety seats.


summary: 748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity

raw_content: During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.

Correction Narrative: An email was received on 09/12/25 from the administrator with the attached corrective action plan: Beginning immediately only children placed at Castillo Children's Center and employees of Castillo children's Center will be allowed to be transported in an agency vehicle.


raw_content: A child's admission assessment, 72 hour plan, and placement document dates do not match.

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

Correction Narrative: Corrective action plan received on 09/12/25 from administrator by email with the following: Beginning immediately the case manager will insure all information contained in the placement authorization. Also forms that are generated by Castill Children's Center will reflect accurate, current, true, and complete regarding the child.


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

raw_content: Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.


Deficiency Narrative: A subsequent service plan for a child did not adress skills for youth 13 and older.

Correction Narrative: A corrective action plan was received by email on 09/12/25 from the administrator with the following: Beginning immediately all service plans will address skills for youth 13 years or older in the appropriate section of the plan of service.


raw_content: A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.

Standard Number / Description: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.


summary: 745.8411(a) - Responsibilities - Not interfere with an inspection or investigation

raw_content: A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.

Correction Narrative:
On 10/08/25, an inspection was performed to the operation and an interview conducted with staff who confirmed staff are not permitted to discuss with residents active or ongoing investigations. Staff stated this was addressed during a staff meeting.
On 09/26/25, an email was received from the administrator with the attached corrective action plan: Effective immediately, no staff shall discuss or question any child regarding an officially initiated investigation.


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 professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.

Correction Narrative:
A follow up inspection was completed to the operation on 10/08/25 and a staff member was interviewed regarding the deficiency. The staff member interviewed identified the staff members do not interview residents or hold conversations with youth that are audio/video recorded. Staff stated that any recordings or photos are of the youth engaged in normalcy activities and not shared outside of operation personnel.
An email was received on 09/26/25 that stated effective immediately staff will not audio of video record a conversation with a youth in placement.


raw_content: Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.

Correction Narrative:
On 10/01/25, the two corrected service plans were received updated/corrected from the case manager.
A second plan received from the administrator on 09/30/25 stated the LCCA and Treatment Director will be responsible for ensuring the plan of service is individualized before signing, the signature of either Treatment Director and LCCA will verify the information is current, true, and accurate and acts as checks/balances for the plan of service. The LCCA further conducted a supervisory consultation with the case manager regarding current, true and accurate records. Administrator added the two service plans reviewed would be corrected and returned by the case manager.
On 09/26/25, a plan of correction was received from the administrator by email that stated effective immediately all information recorded in a child's plan of service shall be individualized for that child. The information will be current, true, and accurate for that child. The corrective action plan was returned for amendment.


raw_content:
During a review conducted on June 17, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months has elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 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 plan, 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 administrators failure to ensure compliance include the following:
Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025.
-	Operation failed to satisfy the conditions of the plan; and
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

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

Correction Narrative: Operation is currently in compliance with all deficiencies


raw_content: During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.

Standard Number / Description: 748.869(a)(3) - Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.

Correction Narrative: In an email received from the administrator on 06/09/25, the plan of correction attached stated the following: Effective immediately all pre-service training will include a certificate, letter, or signed and dated statement of successful completion from the training source. Also attached to the email was the signed/dated training certificates for the employee record that was reviewed.


raw_content: A staff member interfered with an ongoing investigation by discussing the allegations with children in care.

Standard Number / Description: 745.8411(a) - Responsibilities - Not interfere with an inspection or investigation

Correction Narrative:
An interview was conducted with direct care staff and administrator during a follow up HM inspection completed on 07/29/25. While the interview with the administrator revealed he had not completed a training with staff yet, the staff interviewed identified staff were not permitted to discuss with children or other staff active or ongoing investigations.
7/22- An email received from the administrator on 07/22/25, identifies the plan of corrective action as follows: Effective immediately all staff are prohibited from discussing allegations of abuse and neglect in front of or with children in care at the operation. This will be discussed in a staff meeting to be scheduled.


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: During an inspection, prescribed medication was found stored in containers with handwritten labels.

Correction Narrative: On 05/12/25, the plan of correction was received via email from Administrator and stated the following corrective action: Effective immediately all medications will be stored in the original container unless there is an additional container with the same label and instructions from the pharmacy.


summary: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

raw_content: A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.

Correction Narrative: The plan of correction received from the administrator by email on 06/27/25 identifies the following: Effective immediately, medication counts will be conducted when a child leaves on a visitation to ensure that sufficient doses of the child's medications are being sent to cover the entire length of the visit. Effective immediately, any physician's orders will be thoroughly read and followed specifically as directed by the orders. This will include any medication order from a physician.


summary: 748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications

raw_content: A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.

Correction Narrative:
An onsite follow up inspection was conducted at the facility on 06/30/25 regarding the investigation citation. An interview conducted with Case manager confirmed a plan was in place to notify the medical consenters of virtual medication reviews by email or text prior to the appointment, so the medical consenter could authorize consent regarding medication changes or new medications.

The administrator provided the following plan of correction via email on 06/27/25: Effective immediately, all primary medical consenters for children in placement will be notified as soon as any medication review is scheduled. This will allow the primary medical consenter to participate and be able to provide consent for administration of routine, preventive, or emergency medications.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: A child in care did not have TB skin test record or result.

Correction Narrative: The plan of correction received via email on 04/16/25 from the administrator identified the following: Beginning immediately when a child is admitted to the program, and there is no documentation of a TB test, we will request documentation within 3 days of admission. If we have not received the documentation within the 3 days we will then take the child to get a TB test.  Attached to the email were the negative results of the child's TB skin test completed on 04/07/25 (negative result 4/9/25).


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.


raw_content: A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.

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: An email was received from the administrator on 02/28/25 with the attached corrective action that identified the following: The staff in question for this deficiency was given disciplinary action on 02/03/2025. Staff shall not engage in personal conflict with other staff while in the presence of children. Each staff involved has a written supervisory consultation that may result in further disciplinary action.


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

raw_content: During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.

Correction Narrative:
On 01/28/25, the plan of correction for an interim investigation citation was received from the administrator by email. The plan of correction identified: The staff in question for this deficiency was given disciplinary action on 01/17/2025. The disciplinary action for the staff was also received in the email.
On 01/28/25, a follow up inspection was completed. Two staff were interviewed regarding staff sleeping while on shift. The two staff identified that sleeping while on duty was not permitted. One staff communicated that she had not observed any staff sleeping while on shift and the other staff stated that staff had not been observed sleeping recently while on shift, but a report had been made at the time to the administrator. Staff identified that sleeping while on duty was not permitted.


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.

Correction Narrative: On 01/28/25 an onsite follow up inspection was completed and interviews conducted with two staff and two children. The interviews with the staff identified they were aware of safety plans implemented that placed two children on enhanced supervision. The staff were aware of each child's plan for monitoring. Two children interviewed identified that staff supervised them. Older children were not permitted to be around younger children at times. Two children have rooms without roommates. Overnight staff complete 15-minute checks. A plan of correction was received on 01/27/2025 from the operation's administrator by email with the attached plan of correction. The corrective action plan identifies: When children exhibit behaviors or interests that require additional supervision communication between administrative staff and direct care staff will be executed by the staff text thread, phone, and in person staff meetings to discuss increased supervision needs and to develop a strategic plan moving forward regarding these concerns.


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 December 16, 2024, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months has elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 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 plan, 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 administrators failure to ensure compliance include the following:
Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to satisfy the conditions of the plan; and
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Correction Narrative: An HM extension was approved effective 12/16/2024.  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 6/17/2025.


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

raw_content: A child in care was restrained for not complying with staff and was not a danger to themselves or others.

Correction Narrative:
In a follow up conducted at the operation, an interview conducted with staff present at the operation on 01/14/25 concluded staff are trained EBI is only to be used when a child is a danger to themselves or others.

Staff were given a refresher course in EBI on 12/13/24 and a sign in sheet confirmed staffed involved in the incident attended.


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

Correction Narrative:
An email received from Administrator on 11/26/24 identified the following: "Corrective Action: beginning immediately, a notarized Licensing Affidavit for applicants for Employment will be completed and placed in the employee personnel file at the time of hire."
Corresponding attached documents received with the email included the notarized Licensing Affidavit for Applicants for Employment for the employee.


summary: 748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

Correction Narrative:
Email received on 11/26/2024 from Administrator with the following: "Corrective action: Beginning immediately all service plans will be signed by the PLSP or Treatment Director at the time of completion."

Corresponding documents attached to the email included the preliminary service plan, signed by the PLSP and dated 11/20/2024.


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

raw_content: The PM doses of medication for a youth in care were not properly documented.

Correction Narrative: Operation stated that beginning immediately, any medication administered to a child in their care will be immediately, or within 2 hours of administration, documented in the child's medication log.


summary: 748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly

raw_content: During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.

Correction Narrative:
The following email was received from the operation:

"Corrective Action: The slide with the cracks was removed from the playground set and destroyed, all debris has been removed from the playground area, and any board that was broken has been removed and replaced. More comprehensive inspections of the playground area and structure will be conducted weekly."

Additionally, the playground was inspected for compliance at Inspection #4021417 on 09/23/2024 and found to be in compliance.


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

raw_content: Medication logs were filled out incorrectly for a child in care.  Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.

Correction Narrative: Operation indicated staff involved in the incident received refresher training on medication administration and documentation and received a disciplinary action (supervisory consultation).


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: A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM.  Child was being given a full dose by one staff member and a 1/2 dose by another staff member.  Pill count reflected the discrepancy on the medication logs.


raw_content: During the inspection, it was found that a child was not given the correct dose of medication on four occassions.

Correction Narrative:
Received the following email from facility administrator:

CASTILLO CHILDREN'S CENTER
RESPONSE TO DEFENCIES
DEFICIENCY CITED ON 07/16/2024
Deficient Standard # 748.2003(b)(3)
Corrective Action:  When a new medication is received, or a new prescription is filled, the person responsible for medication administration (med tech) will compare the new prescription instructions to old prescription instructions to ensure that the correct prescription instructions are followed. Once the prescription instructions are verified the med tech will administer medications according to the instructions or a prescribing health-care professional's orders.

Additionally, during Heightened Monitoring Inspection #4012508, Medication Logs were reviewed alongside a medication count to ensure compliance. No concerns were observed.


summary: 748.363(12) - Personnel records-Include record of training and training hours.

raw_content: An employee's file did not have an up to date record of all training and training hours completed.

Correction Narrative:
Corrective Action:  All staff training documentation will be placed in the staff file no later than the end of the next business day. This will be tracked by auditing staff files on a weekly basis.
The staff responsible for this will be the Program Coordinator with oversight from the LCCA.
This is effective immediately.


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: It was discovered that staff are denying phone calls from children.

Correction Narrative:
Child interviews conducted at their perspective school to complete additional interviews and follow up. Compliance met.

LCCA submitted corrective plan: All children in care will have the right to send and receive unopened mail, make and receive phone calls, keep journals, and have visitors unless it is not in the child's best interest. This is effective immediately.


summary: 748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP

raw_content: It was determined that staff were listening in on children's phone calls.

Correction Narrative:
Child interviews conducted at their perspective school for follow ups. Compliance met.

LCCA submitted corrective plan: Staff will not listen in on children's telephone calls unless given permission to do so by the child's parents, service planning team, treatment director, or PLSP. This will be effective immediately.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted.  The application does list 5 different references, but the operation does not have any documentation to show where contact was made.

Correction Narrative:
A corrective action for the citation listed above was submitted by Tony Castillo, Administrator.
 Prior to hire an applicant's last five years of work history will be verified and documented and placed in applicant's file. If there is no work history for the last five years a statement from the applicant will be written and placed in the applicant's file.  Attached was a written statement regarding the applicant's five-year work history.

During the inspection on 12/19/23 I observed this updated informed in the staff record.


summary: 748.931(c)(1) - Annual Training- Childcare administrators, PLSP's, treatment directors and case managers who hold a prof. license must have 1hr normalcy.

raw_content:
In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022.  The record does show that it was obtaining for 2023 at the
Texas Childcare Administrator Conference.

Correction Narrative: Corrective Action: LCCA's, PLSP's, Treatment Directors, and Case Managers who hold prof. license will receive 1 hr. normalcy training per year. The Program Coordinator will ensure this training is completed annually.


summary: 748.751(a)(1) - Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.

raw_content: In the employee record reviewed there was no documentation made to show the last five years of employment history.

Correction Narrative:
Corrective Action: Prior to hire each applicant's listed references will be contacted and documented in the Pre-Employment Screening tool. Attached was the Pre-Employment Screening tool to be used at the operation.

During the inspection on 12/19/23 I observed this updated informed in the staff record.


summary: 748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record

raw_content: In one of the records reviewed the documentation for the 40-hour supervised experience is minimum.  It does not include the date or if this is the staff's actual 40-hour shadowing experience.

Correction Narrative:
All new hires will perform 40 hours of On The Job Training prior to being assigned a group of children. This OJT will be documented with dates of the training and the staff who supervised the training. Attached to the email sent was OJT documentation to be used.

During the inspection on 12/19/23 I observed this updated informed in the staff record.


summary: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

raw_content: In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.

Correction Narrative:
Corrective Action submitted by Tony Castillo, Administrator.   Prior to the date of hire applicants will complete the Notarized Licensing Affidavit. An attached Notarized Affidavit for the staff record reviewed was attached to the information submitted.

During the inspection on 12/19/23 I observed this updated informed in the staff record.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.

Correction Narrative: LCCA submitted correction plan. LCCA understands reporting requirements as well as SIR documentation requirements. LCCA will ensure reports are made timely and thoroughly documented any time an individual contracts a communicable disease.


summary: 748.311 - Serious Incident Documentation-Documented in written report

raw_content: In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: In a review of four child records, it was noted that the children were missing TB tests.

Category: Child Care

Correction Narrative: A review of TB tests was conducted. the standard was reviewed and found to be in compliance.


summary: 748.565(3) - Professional level service provider-must review/approve discharge or transfer summaries; sign and date to indicate approval

raw_content: In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.


summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: In a review of one child's file it was noted that the child had not recieved their screening review.

Correction Narrative: All children 10 years of age or older have been administered the suicide screening tool as of October 2, 2023. These children will have the suicide screening tool administered every 90 days thereafter.