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

raw_content: During an outing at a waterpark, staff didnt have an account for two children for twenty minutes.

Correction Narrative:
The Administrator of the operation submitted the following Corrective Action Plan on 09/25/2024:

CORRECTIVE ACTION:
The following actions have been made for correction:
1. Before outings staff will get with children and lay out expectations with youth.  Which is in line with TBRI training.  Listen and mind and stick together
2. Sunny Glen will ensure that adequate staff is available for outings to meet child caregiver ratio or above.  Youth will be assigned to specific staff.  That staff will be responsible for the youth assigned to them.
3. In future outings to outings such as the waterpark, staff will not let lifeguard separate youth from staff.

I conducted a Follow - Up Inspection on 10/07/2024 to address the corrective action plan for the citation issued. Administrator and Director were present during the Follow - Up and concerns were discussed and recommendations were provided as well as positive feedback.


state: TX

facility_name: Sunny Glen Childrens Home

summary: 748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care

raw_content: Two children s placement agreement did not have the reason for placement and anticipated amount of time documented.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Corrected at Inspection: No

Correction Narrative:
The following Corrective Action Plan was submitted by the Director of the operation and it indicates the following:
CORRECTIVE ACTION PLAN
Submitted by the Program Director, LCCA.
LICENSING'S DECISION OR ACTION
DEFICIENCY
Our operation was cited for:
1. 748.1207 (a)(3) Placement Agreement-Must include the reason for placement & anticipated length of time in care
CORRECTIVE ACTION
The following actions have been made for correction:
1.	Sunny Glen Case managers will review and ensure all DFPS forms are completed by DFPS when conducting intakes or prior to placements.


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

raw_content: A staff member was having an inappropriate relationship with a youth in care.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Correction Narrative:
The Director of the Operation submitted the following Corrective Action Plan that indicated the following:

CORRECTIVE ACTION PLAN
Submitted by Program Director.
LICENSING'S DECISION OR ACTION
DEFICIENCY
Our operation was cited for:
1.	748.507(1) Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
CORRECTIVE ACTION
The following actions have been made for correction:
1.	All Sunny Glen Staff who work directly with children will receive yearly mandatory Abuse/Neglect, Boundaries and Normalcy/Prudent Judgment Training.
2.	All incidents will be reported immediately to the Human Resources Department for immediate and/or further disciplinary actions.


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

raw_content: Based on information gathered through investigation and interviews, keys to unlock doors in the home, including pantry, knives, cleaning supplies, and medication are left accessible to children.

Standard Risk Level: High

Correction Narrative: I conducted an UnAnnounced Follow - Up Inspection at the Operation on 12/20/2022 to evaluate the standard cited. During the inspection the keys that unlock doors in the home that lead to the medication, cleaning supplies, and knives were in the possession of the House Lead and the House Parent. The doors to areas where children should not have access to were locked. No concerns were noted during the Inspection and the Operation appeared to be in compliance with this minimum standard.


raw_content: House parent did not show prudent judgment when they raised their voice at youths that were upset and told another staff member not to intervene instead of deescalating the situation

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: Correction received from operation.  Sunny Glen immediately assigned a tenured Direct Care Staff to Josh's Cottage for guidance and support for our new House parents.  Meeting held with management to inform of concerns.   Sunny Glen Supervisors, House Parents, Direct Care Staff and youth held a meeting to be able to openly discuss the misunderstanding which allowed for apologies and discussion.  Operation allowed for the youth to return to their previously assigned cottages.  Sunny Glen House Parents and Direct Care Staff that were assigned to the cottage were re-assigned to tenured staff for mentoring and additional training.  Operation Management conducted a Town Hall Meeting with all staff to remind and review of our Mission Statement and our P.R.O.M.I.S.E to every child.


facility_name: Cal Farley's Boys Ranch

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: One prescribed medication for daily administration has not been administered since 3/9/26.

Category: Medication

Correction Narrative: medication was found compliant


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: Four medications were observed to not be in original packaging.

Correction Narrative: medication was reviewed and found to be compliant.


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

raw_content: One home out of nineteen did not have appropriate mattress covers.

Category: Physical Site

Standard Risk Level: Medium

Correction Narrative: The facility has ensured that all mattresses have appropriate waterproof covering.


summary: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

raw_content: An operation caregiver failed to follow operation procedures when children in care were left unsupervised in a vehicle.

Correction Narrative: An email was received from operation administrator which stated that they met with the staff member involved in the incident and discussed supervision expectations and well as how to manage situations in the future.  This was documented and placed in the employee's record.  The operation has updated policy to include more clear directives regarding transportation during supervision.


raw_content: Overnight caregivers failed to follow operational policies regarding supervision during sleeping hours.

Standard Number / Description: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

Correction Narrative: Overnight staff were re-trained by the operation regarding expectations and supervision policies were reinforced.  Administrative staff have also conducted a review of the camera system at the operation to ensure appropriate checks are being completed.  An email group for overnight staff was created in order to improve communication and ensure that dissemination of expectations and updates are provided to all staff.  Lastly, the operation is now requiring all overnight staff attended the weekly house parent meeting.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: Caregivers failed to ensure that children in care were being supervised according to service plan requirements.

Correction Narrative: An inspection at the operation was completed.  I spoke with the Administrator at the operation who stated that overall supervision was discussed during the house parent meeting. He stated that all house parents and relief staff reviewed the information and signed a memo for record indicating that they are aware of supervision requirements for each youth.  Administrator reported that all staff have access to the child's service plan and supervision level and this information is passed on in daily logs for all staff members.


raw_content: Caregivers failed to provide appropriate supervision when children in care left the home during overnight hours and did not respond to alarms in the home and were aware of children in care going between bedrooms during overnight hours and disabling window alarms.

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

Correction Narrative: An inspection was completed at the operation on 12/23/2025.  The administrator reported that the staff member was terminated on 12/17/2025.  He stated that they have discussed supervision as well as provided additional training during the house parent meeting.  The operation is also implementing securing bedroom doors in some homes during the daytime hours in order to ensure that residents do not congregate in bedrooms.


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

raw_content: Caregivers failed to provide appropriate supervision during overnight hours by not providing routine bedroom checks when safety plans were in place and ensuring that alarms in the home were appropriately turned on and functioning.

Correction Narrative: This standard is compliant.


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

raw_content: A caregiver utilized inappropriate language in the presence of children in care.

Correction Narrative: An inspection at the operation was completed on 12/23/25.  Operation administrator reported that they met with the staff member and completed a memo of record on 12/4/2025 in which it was reiterated to the staff that any inappropriate language is not permitted in the presence of children in care. This information was also discussed during the house parent meeting.


raw_content: A caregiver failed to demonstrate self-control and good judgement when he poked a child in care and did not maintain appropriate personal boundaries.

Correction Narrative: The operation has placed the staff on a developmental plan which talks about boundaries with children in care as well as operational policies.  Follow up will be conducted at least ever 2 weeks.


raw_content: Caregivers were not providing supervision to children in care as required by the child's service plan.  The service plan indicates that children in care must be checked on every 15 minutes and caregivers indicate that they often check on residents one time per hour.

Standard Number / Description: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

Correction Narrative: Operation staff have been spoken to regarding supervision.


summary: 748.2301(b)(1) - Disciplinary Measures-must be consistent with operation policies and procedures

raw_content: Children in care were given an early bedtime for setting off bedroom alarms in emergency or non-emergency situation, which is not permitted in operation policies.

Correction Narrative: An email received from operation administrator indicated that all campus staff were re-trained regarding the therapeutic discipline procedure for the operation.  They have ensured that all direct care staff are aware of what is permitter per minimum standards as well as the operation policies.


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

raw_content: Caregivers failed to ensure that all cleaning supplies were properly secured following use by children in care.

Correction Narrative: The operation has completed a houseparent meeting which included ensuring that all direct care staff will complete a daily sweep of the home to ensure that cleaning supplies are removed and appropriately stored.  An inspection completed at the operation on 3/6/25 as well as 11/27/24 and all cottage homes were inspected.  No cleaning supplies or dangerous chemicals were observed.


raw_content: Caregivers failed to follow the supervision instructions for a child in care which resulted in a child being injured during a physical altercation.

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

Correction Narrative: Physical follow up completed on 8/8/2024 as part of inspection id 4014013.  The administrator for the operation reported that the staff involved in the incident have been retrained regarding the supervision requirements of the youth in the home as well as expectations and policies for supervision at the operation.  All house parents on campus were provided with an email describing supervision inside and outside the home.  The administrator reported that they plan to discuss supervision with all house parents when school resumes and they have their first house parent meeting of the year on 8/21/2024.


raw_content: Staff members chased a child in care who had taken a vehicle belonging to the operation without permission. Speeds were between 40 mph to 80 mph. The child knew he was being followed and could have been involved in a car accident where he could have been seriously injured.

Correction Narrative: An email with updated policies was received from the operation administrator.  They have updated policies to include how they should handle situations if a child leaves the operation without permission in an unauthorized use of a vehicle.  The policy states that the staff will follow the child to determine what direction they are going and will abide by all traffic laws while following and not exceed the speed limit or drive in an unsafe manner and must also notify law enforcement regarding the situation and follow any instructions provided by law enforcement.


summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: One home had expired over the counter medication observed with current medications.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: A caregiver did not release a child after the child was calm and no longer a danger to himself or others.  The child reported to the caregiver that he was in pain during the restraint and the caregiver also failed to release him in a timely and appropriate manner.

Correction Narrative: An email received from operation administrator stated that the staff member involved in the incident is no longer employed at the operation and was terminated immediately following the incident.  The operation has completed a policy review with all direct care staff which reviewed the areas of concern.  This information will also be reviewed during staff meetings.


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

raw_content: A caregiver humiliated and ridiculed a child when he was unsuccessful completing a task.  This occurred in front of other children in care.


summary: 748.2551(b)(3) - EBI Implementation-The caregiver must consider the potential risk of harm in using EBI versus the risk of not using EBI

raw_content: A caregiver failed to reduce the risk to a child in care when a child was restrained without the presence of a second staff.  The other children in care were present and continued to ridicule the child and kick the child during the containment without redirection from the caregiver. The caregiver failed to release the child from the containment when it was determined that he was not doing a proper hold until he was instructed to do so my administrative staff.


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

raw_content: Caregivers failed to provide a safe environment and proper supervision resulting in a child in care using the hot tip of a candle lighter to burn another child in care.


summary: 748.1433(d) - Discharge-If child not receiving tx svcs, tell him of non-emergency discharge/transfer 4 days in advance, unless LCCA or PLSP justifies not doing so

raw_content: A child was notified of his discharge the day before he was discharged. The discharged documentation did not have the justification for the child not being informed four days in advance of the non-emergency discharge.

Correction Narrative: A follow up was completed at the operation and the operation has updated the discharge template. The have added If not given 4 days' notice, a LCCA must provide rationale for such to their discharge summary template, and they have also added a time box to be filled in on the template for when a resident is notified.


raw_content: 8 child records reviewed did not include information specific to the discipline techniques utilized by the operation.

Correction Narrative: An email received from operation administrator shows the information related to discipline has been added to the service plans under the section of "identified needs."  The operation stated that there will be a reference in all service plans to their Therapeutic Discipline procedure, which includes the child's preferred de-escalation techniques, as well as previous discipline which has been proven effective for the child.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: The storage closet utilized for recreational supplies was found to be not appropriately secured and allowed unsupervised access to children in care.

Correction Narrative: The storage room was appropriately locked and secured.  No concerns were noted.


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

raw_content: A caregiver failed to use prudent judgement when he allowed a female resident to enter the male community

Correction Narrative:
An email from the operation administrator contained a corrective action plan regarding this citation.  The staff member involved in this citation has been placed on a Performance Improvement Plan for the following 90 days which includes shadowing a more seasoned on-call worker, utilizing on call regarding additional assistance on how to handle certain situation, review of supervision and transportation procedures for the operation, as well as re-training in SAMA.  The operation also determined that the staff member may have been distracted as his child was with him during this event, and therefore may have had to divide his attention between the child in care, and his child.  The operation stated that they have updated staff members and ensured that they are aware that they must be able to preform assigned duties without having to be responsible for care for their own children.

Physical follow up was completed on 6/22/23.  Copies of the signed performance plan were reviewed as well as a discussion with staff member's supervisor.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: A caregiver used sarcastic comments in order to manage a child in care's behavior.

Correction Narrative: An email from the operation administrator shows that the staff member was placed on a performance improvement plan, which included additional trainings and bi-weekly meetings with mentors in order to assist with better developing skills related to the population that the operation serves.


summary: 748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes.

raw_content: An electrical fan was located in the pool area near the water.

Corrected at Inspection: Yes


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

raw_content: Two child's medications were not given as prescriA child was prescribed Cipro/Dexa to be given every 12 hours for 7 days.  The medication was only given for 5 days.  Another child was prescribed Clindamy/Ben Gel to be applied to the area twice daily inthe morning and evening for acne and on 9/30 and 10/1 the medication was only given once.

Correction Narrative:
An email was received from operation administrator which states that procedures for distributing medications has been reviewed with house parents, including giving medication as prescribed.  The operation also updated internal procedures related to picking up prescription medications in a timely manner.

Follow up was completed at the operation on 10/11/2022.  Medication was reviewed and found to be in compliance and appropriately administered to children in care.


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

raw_content: Two staff members out of 11 did not have normalcy training as required by Minimum Standar requirements.

Category: Training and Professional Development

Correction Narrative: An email was received from the operation which stated that that did not have normalcy training have now completed the training. It was done prior to them being able to work at the operation.  At the house parent/direct care staff meeting on 10/5/2022 it was discussed with that all annual training must be completed prior to the due date.  The training reminder system was reviewed and found to be working properly.


raw_content: Bleach was observed in the dish room of the facility and accessible to children in care.

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

Correction Narrative:
An email was received from operation administrator.  She stated that following the inspection all chemicals were immediately secured.  They checked the locks and ensured that appropriate staff had a key.  Dining staff have all been reviewed on the requirement of cleaning chemicals being appropriately secured.  For the following three months, there will be weekly checks to ensure that the cleaning supplies are appropriately secured.

Inspection completed on 9/23/22 which confirmed that cleaning supplies were appropriately secured.


raw_content: A caregiver yelled and slammed a door in the presence of children in care.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative:
An email was received from operation administrator.  The facility has placed cameras in all common areas of the home. The caregivers in the home have completed additional EBI training.  They have also reviewed the policies and procedures regarding discipline, employee code of conduct and client/adult interactions.

Follow up completed by inspection on 9/23/22.  I spoke with a staff member and a child in care.  It was confirmed that the caregiver had been retrained regarding the policies regarding discipline at the operation.


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

raw_content: One bathroom was observed with a shower light hanging with electrical wiring exposed.

Correction Narrative: Follow up was completed at the operation on 4/6/22.  The previous concern with the shower has been corrected.  the operation continues to use a check list for the staff to do a thorough review of each home on a monthly basis to ensure that the homes remain in good repair.  The operation also uses a work order system where any repairs that are needed are turned in and fixed as soon as possible.


raw_content: Overnight staff failed to use prudent judgment by leaving children at home without ensuring relief staff had arrived.  Staff authorized to provide respite care failed to follow-up when children did not arrive at the respite cottage.

Correction Narrative: During a follow up inspection 3/3/22, it was discussed that the operation has spoke with all staff, especially overnight staff, that they are to ensure there is relief prior to leaving the home.  If a relief person does not arrive or is not present then they are to contact management.  The staff member that was directly involved in this incident was seasonal, and is not employed at the operation.


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

raw_content: Three children in care, ages 17, 16, and 15, were left unsupervised for 2 and a half days.

Correction Narrative: A follow up inspection was completed at the operation on 3/3/22.  The operation has developed new protocols to ensure that during respite children are always accounted for.  The operation has also updated the alarm system to include notification to home life supervisors, which would have benefited during this particular situation.


summary: 748.2101(1) - Medication Storage-Store medication in a locked container

raw_content: Medication was observed to be unsecured in three out of seventeen homes.

Correction Narrative: The operation has reviewed medications and ensured that all self adminstered medications had the appropriate labels. The supervisors have reviewed all medications to ensure that everything is up to date.


summary: 748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill

raw_content: Thirteen out of seventeen homes have not had a fire drill or severe weather drill within the past six months.

Category: Safety and Emergency Practices

Correction Narrative: Fire drills for all homes with occupants have been completed.  These will be done on a quarterly basis in order to ensure that all residents in the home are aware of the procedures related to homestudies.


raw_content: Seventeen homes were observed at the operation.  Concerns included numerous bedrooms having open food items, lighting needing to be replaced, sinks that did not properly drain, and mold in the showers.

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

Correction Narrative: The supervisory staff have ensure that the homes have been appropraitely cleaned.  They have changed chore schedules to ensure that the home is appropraitely cleaned.  They have provided the staff and residents with the process of deep cleaning different areas of the home.


raw_content: A caregiver did not adequately supervise children in care which allowed two teenagers to engage in sexual intercourse.

Correction Narrative:
Email from Operation: Corrective Action Plan
Implemented Immediate:
Home perimeter systems - It was discovered that the south rear door of the home only chimed during the daytime hours however after the alarms are activated they functioned as expected.

On May 5, 2021  Youth Program administrators and Business Operations staff met to discussed home security systems specifically  rear and side doors alarms. It was decided that rear and side doors of the residents homes will be armed at all times.  Maintenance completed the task and notified Home Supervisors upon completion.

Memo For Record dated 05/08/2021  Lead Home Supervisor documented a verbal conversation he had with Earl Home house parent and  reviewed the above incident with the house parent involved. This house parent was instructed by  to ensure that either visual or auditory confirmation that the resident is present and safe when completing routine 15 minute checks.

On May 12, 2021  During weekly house parent meeting, all direct care staff was informed that rear and side doors will be armed full time.

MFR dated June 21,2021  Mr. Wilsher, home supervisor reviewed Supervision and Transportation of residents' procedure with staff involved focusing on active supervision and 15 minutes checks of residents.
b.	Ongoing
Administrative review of campus procedure  Supervision and Transportation of Residents specifically the routine 15 minutes checks and residents are in the bathroom.  The procedure was revised to reflect the following changes:
Supervision of Residents Inside the Home:
A. Residents are to be supervised in the home, according to their supervision levels and level of responsibility. No resident will go for extended periods of time without being seen by a direct care staff.
B. There should be frequent checks (at least every 15 minutes) on children when they are in their rooms.
C. If during routine 15-minute supervision checks, staff discover a child is in the bathroom/shower with the door closed staff will do the following:
a. Knock on the bathroom door and prompt a verbal response from the resident.
b. If the resident does not respond, staff will knock on the door a second time and then provide a warning that they will have to open the bathroom door.
c. If no answer from the resident, the staff will knock a third time and open the door wide enough to verify if the resident is in the bathroom or shower. If so, staff will promptly close the door and ask the resident if he/she is ok.
d. If child is ok, follow up with child once they are clothed and out of the bathroom regarding the need to respond when asked and notify the home supervisor or on call staff of the need to have opened the door.
e. If a child is not present in the bathroom, follow procedure to report a missing resident.
f. It is important to make all children aware of this procedure to encourage their cooperation in responding.


raw_content: Children in care were not provided with appropriate supervision when at an off campus activity and were able to leave hotel rooms without staff being aware and engaged in consensual sexual behavior.

Correction Narrative: Walkthrough coducted in the cottages. Interview with cottage parents conducted and new policies implented ensuring there is an awake overnight staff during away trip.


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

raw_content: The caregiver used profane language, made verbal threats, and made vulgar gestures when disciplining children in care. The caregiver engaged in a verbal altercation with a child in care and would not allow the child to separate themselves from the altercation.


raw_content: A caregiver engaged in a discussion with children in care about the caregivers personal sexual activities and preferences.  A caregiver failed to maintain appropriate boundaries with children in care to include begging children in care to comply with requests.

Correction Narrative: Caregivers were released from their duties. Intervew with current caregiver were conducted.


facility_name: Boysville Inc

raw_content: (AP) A child did not receive precription medication as prescribed for pain.

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

Correction Narrative:
The operation provided the following compliance and corrective action on 02.26.26: Training was conducted to illustrate that all medication must be followed utilizing the written instructions provided by the healthcare provider. Staff in this cottage will be completing medication audits of all their medications every Monday and Friday Mornings. Administrative staff will review the medication audits of this cottage no later than 24 hours after completion. The training login sheet and medication audit form was provided.

Additional compliance will be completed.

Follow up was completed for citation issued during the 02.17.26 HM inspection related to 748.2003(b)(3) in person on 03.02.26. Medication audits will now be completed by the Girls cottage staff every Monday and Friday. These audits will be reviewed by leadership, while leadership conducts their independent medication audits on Wednesdays. The Ridgeway and Trease staff will be required to attend in-person medication review training during April/May. Medication was reviewed as administration matched the label instructions and documentation.


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

raw_content: While reviewing a child record, admitted on 12.31.25, it was observed the preliminary service plan has not been completed,

Standard Risk Level: Medium Low

Correction Narrative: On 01.07.26 the operation provided compliance via email detailing a cognizant plan of placing children during the holidays and maintaining specific timelines for required paperwork to be completed. The preliminary service plan was completed on 01.06.26.


raw_content: A direct care staff left a child in duress unsupervised which resulted in the child eloping from the operation.

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

Correction Narrative: A discussion was held with the operation on 01.06.26. The operation informed a cottage meeting was held and deep dived into the scenario that caused the citation. Staff voiced understand how to handle situations such as these going forward.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: Medication is missing from a child's bottle of prescription medication. The operation does not have documentation regarding the error.

Correction Narrative: Medication binders within each cottage were to reviewed. Each binder contained administering medication procedures, prescribed medication protocol, sample of completing medication log information, documenting medication errors procedure, and sample of documenting medication errors.


summary: 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

raw_content: A child in the care was administered three doses of psychotropic medication without prior authorization from the legal guardian.


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

raw_content: A review of the medication logs revealed that one medication log for a resident did not include the reason for prescribed medication.

Correction Narrative:
The operation provided the following compliance on 09.16.25:

Staff have been recently training on medications. a sample of a medication log has also been placed in the medication log to document what needs to be filled in when cottages receive any new medications.


summary: 748.3603(f) - Swimming-Fence gates to outdoor pool must have self-closing/self-latching hardware 60 inches from the ground and must be locked when pool not in use

raw_content: It was observed during a Heightened Monitoring visit the self-latching hardware device on the pool gate was not working properly preventing proper closure within minimum standards.

Correction Narrative: The pool gate was observed and would close properly as well as lock properly.


raw_content: The operation administered psychotropic medication to a child without first receiving the proper consent.

Standard Number / Description: 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

Correction Narrative: A discussion was held with leadership on 07.10.25 to discuss the new procedure more in detail. Staff are to facetime the clinical Director and obtain a verbal confirmation if the operation has received consent of administration from the youth's caseworker. If this is unable to be determined, the medication is stored and not administered until verification.


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

raw_content: Audio recording reflects staff yelling at resident.

Correction Narrative: A discussion was held with the operation. The AP related to the investigation is no longer with the operation as of 05.09.25. The operation provided separation paperwork for review. Remining staff in the specific cottage received a refresher training for TBRI on 06.12.25. This training discussed using certain principles under the categories of empowerment, connection and correcting to address youth behaviors in the appropriate manner.


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

raw_content: Audio recording reflects staff using profanity when confronting resident.

Correction Narrative:
Corrective Action was provided by the operation on 07.10.25: Due to the nature of the incident, the staff involved in this incident was released from her job duties at the operation, as of May 9, 2025.

Staff in the residential program received additional training regarding TBRI (Trust Based Relational Intervention) on June 12, 2025, by the operation's SPARK Program Director. This training was to continue to emphasis ongoing principles and strategies as well as behavioral management techniques to use with the youth they work with.

Additional in-person follow-up completed in 07.24.25. A discussion was held with the operation. The AP related to the investigation is no longer with the operation as of 05.09.25. The operation provided separation paperwork for review. Remining staff in the specific cottage received a refresher training for TBRI on 06.12.25. This training discussed using certain principles under the categories of empowerment, connection and correcting to address youth behaviors in the appropriate manner.


summary: 748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review

raw_content: A fire extinguisher observed during a walkthrough of the operation did not have the necessary documentation of annual inspection.

Correction Narrative: The operation provided a compliance response by email showing that a new fire extinguisher with a valid inspection tag has replaced the previous extinguisher.


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

raw_content: During a walkthrough of the operation physical site concerns were found which included exposed electrical panels and outlets, a hole in the wall, dirty air vent and exposed wires from wall.

Correction Narrative: The operation provided compliance via email on 06.11.25. The operation provided pictures showing the cleaned air vent, repaired hole in the wall, the Electrical cover replaced, the Doorbell cable removed and covered.


raw_content: During interviews with children in care it was found a staff member was using profane language toward children in care.

Standard Number / Description: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Correction Narrative:
The following compliance was provided on 05.14.25 via email:

The childcare staff has been given a written warning and placed on a performance improvement plan. The staff member has been provided with training regarding children's rights. The staff member will also be meeting with Boysville's parenting coordinator on a weekly basis for 30 days to review and assess appropriate communication with minors. This will begin the week of May 19th, 20025. The residential program director as well as the case manager of the cottage will be completing weekly checks ins with the residents to ensure their rights are not being violated.

Additional follow-up was completed on 05.28.25 at the operation.


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

raw_content: Staff should not threaten the children in care with the use of physical punishment at any time.

Correction Narrative: Compliance was met by reviewing the coaching documentation for the specific staff.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: Staff was telling children in care that their families do not love them and she does not care about their families.


summary: 748.343(2)(A) - Records protection policies - Clarify persons within operation authorized to access records

raw_content: Operation staff confirmed that another staff had unauthorized access to records.

Correction Narrative:
On 03.20.25 the operation provided the following compliance with all completed documentation to include sign in sheets, training certificates and the training curriculum from 03.05.25:

1.  Boysville will provide INFORMATION SECURITY AND CYBERSECURITY training during our scheduled training week from March 3 to March 7 (Wednesday the March 6, 2025) for all staff with access to TDFPS database systems. This training will cover essential security principles, best practices for password management, email security, social media safety, mobile device security, identity theft protection, and data privacy. It will also focus on the PACES requirement regarding database use, emphasizing that only authorized staff are permitted access and that sharing passwords is strictly prohibited.  Certifications will be issued to demonstrate proof of training and will be sent to the RCM by March 14, 2025. A list of staff members with access to any TDFPS database systems will be provided to the RCM to verify completion of the required training. The list of the staff members will be pulled from Paycom.

2. The CEO, is responsible for developing and implementing the training plan for information security and cybersecurity. After the training is completed, random checks will be conducted to ensure that PACES passwords have not been shared. During these checks, PACES users will be required to sign a confidentiality statement confirming that they have not shared their passwords.

3. The Performance Quality Improvement (PQI) Safety Chair, will report the results of these checks at the quarterly PQI meeting. The random checks will begin in April, although the exact dates have not yet been determined, coinciding with our next quarterly review. The results of the random checks will be sent to the RCM by April 30,2025.

If a staff member is unable to access any TDFPS database using their password or login ID, they should reach out to the Training Compliance Specialist for help. If the Training Compliance Specialist is unable to resolve the issue, the staff member will be advised to contact the TDFPS help desk or the RCM for further assistance.


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

raw_content: Operation evacuation plans do not include severe weather interior shelter location.

Correction Narrative:
Operation advised that Boysville Emergency Evacuation plan has been updated to include
sheltering in place due to severe weather and placed in all cottages/buildings on campus. Boysville will conduct this drill twice a year.
Boysville will incorporate training into Boysville's DERP procedures for all new
employees to indicate where employees and residents will go in case of severe weather. Training will be conducted as new employees as well as for annual training for employees.

-Photos of all corrected cottage evacuation plans were provided by operation.


summary: 748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period

raw_content: Operation did not have evaluation available for licensing to review

Category: Reports and Record Keeping

Correction Narrative: Operation advised that this report will be discussed at Boysville's Quarterly PQI Risk Assessment Meetings and provided assessment.


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

raw_content: Five children interviewed stated that a child was being physically grabbed, and caregiver did not say anything to ensure childs safety and did not intervene.

Correction Narrative: Boysville staff received training in regard to this specific standard. Staff have a good understanding of correct ratios for child/caregiver. Going forward, all new staff will be given training on child/caregiver ratios by the emergency shelter staff director.


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

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

Correction Narrative:
07/23/2024, compliance plan received for the following citation. Operation indicated the employee involved in this case was terminated upon hearing of the allegations. Boysville Director of Residential Care conducted a training with all staff on 6/5/2024 to discuss supervision and employee conduct.

F/U inspection was completed for separate investigation related to same allegations on 6/19/24. Therefore, the following in person inspection has already been completed and additional information from compliance plan is approved.


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: 3 out of 6 storage facilities were unlocked and contained dangerous flammable chemicals.


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

raw_content: Three out of four children stated they were not aware of the staff's location when a child was walking around with a sharp object in their hand.

Correction Narrative:
On 05/28/2024, extension was granted in person during inspection for new compliance date 6/12/24, from 5/31/24. This to allow operation to provide training for staff.

In person follow up conducted on 6/19/24. 3 staff and 3 children were interviewed and confirmed that additional training was completed regarding line-of-sight supervision. Policies are being posted in each cabin and that was confirmed at inspection.


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

raw_content: Staff member took child in care on unauthorized outing in personal vehicle. Staff member also took several children in care on another unauthorized outing and left them alone to complete a personal online transaction.

Correction Narrative: In person follow up confirmed staff were provided training regarding supervision. Staff were also being required to complete  an activity request form when leaving campus with children. Any off campus activities must be approved before occurrences. Last minute activities will also be called in for approval.


summary: 748.685(c)(6) - Implement and follow the children's service plans.

raw_content: Children in care were left alone during unauthorized outing for a period of time that exceeded service plan supervision requirements.

Correction Narrative: In person follow up confirmed that supervision summaries were posted in each cottage office. Service plan training/guidance was provided to staff to ensure awareness of any changes to individual supervision requirements.


raw_content: Staff locked children outside of the home unsupervised.

Correction Narrative: In person follow up confirmed training was provided to child care staff which covered supervision requirements.


raw_content: Operation staff was confirmed to have a pattern of falling asleep during overnight shift.

Correction Narrative:
Boysville has had the electronic check in wands fixed since the investigation occurred. The were broken for a time period and have been fixed. They are being
monitored by the Training Specialist and Director of Residential Care. A night monitor also randomly checks the night staff to ensure they are awake and following proper procedures.


summary: 748.1791(b) - Basic care requirements for a toddler-caregiver must ensure that the environment is safe

raw_content: Kitchen cabinets were unlocked and accessible to children in care.


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

raw_content: Three of the six cottages had unlocked storage facilities with poisonous chemicals stored inside.


summary: 748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them

raw_content: Residential Child Care Regulation observed West Cottage with no evacuation plan posted.

Correction Narrative:
10/26/2023, Email received from operation staff, advising that an evacuation plan was posted in West Cottage on the next business day. The evacuation plan is on the monthly and quarterly walk-through checklist that is conducted by the Director of Residential Care, Training and Compliance Specialist and Director of Facilities. The review of the checklist is overseen by the Safety Committee in the Performance and Quality Improvement Program.

Inspector also conducted an in person walk-through of the facility during a routine monitoring inspection on 10/23/23 and confirmed that evacuation plan was posted in all cottages to include the West Cottage.


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

raw_content: Operation did not have severe weather drill every 6 months as required.

Correction Narrative:
Operation Evacuation and Disaster Plan Policy has been updated to reflect the inclement weather drill occurring every six months.

-An evacuation drill was conducted on 8/24/23. Proof of drill was provided by the operation.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: Children in care reported to operation staff they had contraband present in their room and operation did not report to licensing once they were made aware.

Correction Narrative: Incident was called into State Wide Intake and an investigation was opened. Operation will call in all future incidents involving contraband as they are now aware that they are reportable. Administrator is made aware of all incidents on campus and will ensure that future incidents are called in.


summary: 748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.

raw_content: Operation admitted they do not keep an annual summary log of unauthorized absences and was not able to provide to licensing at the time of visit

Correction Narrative: Operation created template for Unauthorized Absence log and provided a copy for licensing review. A meeting was also held on 8/24/23 with all programs to discuss implementation and completion of the log.


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

raw_content:
Licensing was not notified timely of children in care running from staff at outing.

Incident occurred on 7/04 at 10:00 pm

Statewide Intake was notified on 7/05 at 10:03 am

This is more than 6 hours required reporting to Licensing.

Correction Narrative:
Case management and on-call staff were notified of licensing requirements of notification of guardians, law enforcement and licensing when a serious incident occurs. They were also given a copy of the Standard 748.303 to have access for
reference when serious incidents occur.


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

raw_content:
Parents were not notified timely of children in care running from staff at outing.

Incident occurred on 7/04 at 10:00 pm

Parents were notified on 7/05 at 9:37 am

This is more than 6 hours required reporting to parents.


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

raw_content: Medical Logs do not show reason for prescribed medication.

Correction Narrative:
Email Received from operation- On August 31, 2023 the Director of Mint updated the Medication Logs and informed staff via email to utilize the correct forms immediately. All Medication Logs were switched out for all residents. A meeting was scheduled for September 8, 2023 to inform all staff (in person) but due to a COVID outbreak in the program, the meeting was postposed until September 28, 2023 where it will be reviewed.

-Copy of new forms being used by operation were also provided.


summary: 748.1531(b)(2) - Medical Care-Written record of each medical examination must include the follow-up treatment recommended and any appointments scheduled

raw_content: The medical records provided for the two children seen in the ER did not include verification follow up appointments with the PCP were completed. Hospital staff noted each child should be seen by the PCP within 1-2 or 2-3 days.

Correction Narrative: Email received from operation with the following information:  The Case Management Supervisor spoke with the Residential Care Administrative Assistant on July 21, 2023 about the importance of following the instructions from the hospital discharge paperwork. She was also instructed that if the PCP is booked during the timeframe from the hospital, to find another provider for the follow up appointment to ensure it is in compliance of the doctor's orders.


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

raw_content: Operation did not seek medical care when child's symptoms did not improve after first aid was provided.

Correction Narrative: Additional training was conducted both individually and in a staff meeting to address immediate medical care for children in care.


raw_content: Staff member chased and pinched child in care.

Correction Narrative: Individual conversation conducted with staff member involved to review appropriate boundaries and additional training conducted with all staff regarding TBRI.


summary: 748.1337(b)(1)(A)(ii) - Initial Service Plan-Include dental needs, including scheduled dental exams and plans for recommended follow-up treatment

raw_content: One service plan reviewed did not have dental information for child in care.

Correction Narrative: As of 2/1/23 all Case Management staff were retrained on completing Service Plans. Case Manager Supervisor will also review all service plans upon completion to ensure that all areas of the plans are completed accurately. Follow-up inspection was completed on 03/15/23.


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

raw_content: The child in care was on a safety plan and was to remain in the staff's line of sight. The operation staff were in the office while the child was in another room where the child could not be seen.

Correction Narrative:
Corrective Action Plan received via email explaining that Boysville's safety plans will be more detailed in the supervision within the cottage and in the community to allow staff to conduct job responsibilities while ensuring the child's safety. The Case Manager Supervisor will review all safety plans.

In person follow-up was conducted by Inspector on 4/11/23; no safety plans had been completed to allow for review however supervision plans in recently completed Service Plans were reviewed and appropriately describe supervision requirements for children in care.


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

raw_content: Medication records were not provided or available for child in care.

Correction Narrative: Operation has created one centralized location and process for all completed and discontinued Medication Logs to be turned in to.


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

raw_content: Psychotropic training for staff member was not completed timely.

Correction Narrative: A Training and Compliance Specialist has been hired by the operation to ensure that all training has been completed within the required timeframe.


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

raw_content: Children in cares service plan states the child will be within line of sight at all times. It states child in care is allowed to go to campus park, gym and outside being accompanied by staff.

Correction Narrative:
Plan received from operation advising that all staff working with residents will sign off service plans to ensure they are aware of any restrictions. A copy of the service plan will also be in the cottage so the staff are able to refer to it at any time. All staff will sign to verify they have received and reviewed a copy of the service plans.

1/26/23, Inspection ID 3925059: In person follow-up was also conducted and sign in sheet and description of training provided to staff on 1/23/23 regarding the service plans was provided. Full walkthrough was conducted and interviews with children in care who were present was completed and documented in chronology. The interviews were addressing supervision provided by operation. No additional concerns came up at this time.


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

raw_content: Inappropriate language was used by staff members toward child in care during a disagreement.

Correction Narrative: Staff that engaged in inappropriate language were terminated immediately. Boysville does not tolerate such behavior from staff towards residents. Director will ensure all staff are aware of Boysville's policy.


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: Upon review of the initial service plan, it was discovered there are not signatures of the service planning team members that were involved in the development of the service plan.

Correction Narrative:
 Case managers have been trained on the importance of signatures of all
participants on Service Plans. The Case Manager Supervisor will ensure all components of
Service Plans will be completed prior to approval.


summary: 748.1337(b)(1)(K) - Initial Service Plan-Include names and roles of persons who participated in service plan development

raw_content: Upon review of the initial plan of service, it was discovered there is no identification of all that participated in the development of the plan, nor are there signatures or dates on it.

Correction Narrative:
 Case managers have been trained on the importance of documenting all
participants involved in the Service Plans. The Case Manager Supervisor will ensure all
components of Service Plans will be completed prior to approval.


summary: 748.303(a)(3)(B) - Serious Incident-Report to parents allegations of abuse, neglect, or exploitation of a child directly after ensuring the child's safety.

raw_content: Operation staff indicated a child in care's claim of being sexually active with an adult while on runaway status was not reported to the DFPS hotline.

Correction Narrative: Staff were spoken to regarding the standard and to contact DFPS for all suspicions of abuse/neglect and reviewed Boysville's policy.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: All five residents interviewed stated that they saw or were present when staff smoked in the facility.

Correction Narrative: Staff was placed on a 4-day unpaid suspension with a written warning. A drug test was completed on staff and they will be subjected to random UA's. Staff was also trained on policies/licensing standards and expectations.


summary: 748.1661(d) - Tobacco Products-No one may smoke tobacco products, e-cigarettes, or vaporizers  in motor vehicles when transporting children in care

raw_content: All five residents stated that staff smoked while transporting resident in the vehicle.


raw_content: Child in care was subjected to profane language by staff during an incident, while other children in care witnessed this behavior.

Correction Narrative: Operation emailed Inspector stating staff member involved was terminated on 08/26/2022. All staff are trained to use appropriate language toward and around children in care. Staff are trained to not use profanity around all children. Operation stated they will not be AR'ing this citation.


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

raw_content: Child in care obtained access to staff operation keys and was able to gain access to the locked medication closet within the cottage during an incident.

Correction Narrative: Email sent from agency to Inspector stating staff have been trained to ensure the medication closet key is in their possession at all times and inaccessible to children. Staff member involved was terminated on 08/26/2022. Operation is not requesting an AR.


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: Child in care was administered a medication by staff that was prescribed to another child in care.


raw_content: Three children in care were allowed to go into a store without supervision from caregivers.

Correction Narrative: The operation provided a follow-up to the deficiency stating that supervision practices and policies will be reviewed with all staff in the month of August 2022.


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

raw_content: It was confirmed that staff members took children in care  on an unauthorized trip away from the operation. Staff allowed an unapproved individual to have access to the children.

Correction Narrative: The operation provided a follow-up to the deficiency stating that staffing was completed with all staff to discuss policy regarding trips away from the campus. This was completed on 07/09/2022.


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: A child in care was not properly restrained in his car seat while being transported in a vehicle.

Correction Narrative: The operation provided a follow-up to the deficiency stating that vehicle safety training was completed with all staff on July 20,2022. Additional car seat safety training will be completed for all staff before August 30, 2022.


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

raw_content: Staff members will regularly yell at children in care when they are misbehaving.

Correction Narrative: The operation provided a follow-up to the deficiency stating that consultation was completed with the staff member in question and feedback was provided. Follow-ups will be completed with staff member during supervision.


summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: Incident at operation was not reported to licensing as required.

Correction Narrative: All case management staff have been informed of all policy and procedures regarding notifying licensing. The Compliance Director is overseeing case management to ensure all incoming case management is aware of Boysville's expectations.


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

raw_content: Communication between staff was inefficient to ensure children in care were provided the level of supervision needed at night.

Correction Narrative: Boysville will ensure more communication between case managers between programs occurs. Case managers will meet with the previous program to ensure all pertinent information is obtained and followed through.


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

raw_content: Observed 3 out of 8 bathrooms contained mold in the shower.


summary: 748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate

raw_content: Child in care was not in own bed at night for sleeping.

Correction Narrative:
November 17, 2021
Boysville has completed the compliance plan in reference to the findings on investigation.
Standard 748.3365(a) Bedding must provide each child with an individual bed or bunk bed in childs room that elevates mattress off floor, or crib as appropriate.
A child in care was not in their own bed at night for sleeping.
Due to staffing issues our girls cottage were combined for the overnight shift. One residents refused to sleep in her assigned room, stating she was sleeping on the floor of another residents room. She later stated she did end up sleeping in the same bed as the other resident.
The child care staff that was on duty that evening, was spoken with and given more detailed instructions on what to do if a child in care refuses request that could hinder protocol. Training over minimum standards  were reviewed with the staff to ensure her knowledge of guidelines that should be followed.


facility_name: Connections

raw_content: A staff member used profane language in speaking to a child in care.

Correction Narrative: The staff member that used profane language was given a corrective action plan and coaching by the administration. The operation's staff members also participated in a training on regulating one's emotions in high stress situations. I obtained the corrective action plan and the training sign in sheet. I also spoke with the administrator who explained the steps taken to come into compliance including corrective action plan, coaching, and staff training.


raw_content: A staff member used profane language directed at a child in care.

Correction Narrative: F/U for Inspection: # 4060564- On 10/22/2025 an unannounced follow- up monitoring inspection was completed at Connections. The follow up was for a citation received through investigation #50730402. Citation response was received on 10/16/25, staff members had meeting to discuss coping mechanisms, de deescalation techniques and ways to cope with stress management.


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

raw_content: During the course of the investigation it was determined that a child in care did not receive their prescription medication as prescribed by a medical professional.

Correction Narrative: On 06.18.25 a follow up inspection was conducted in person. Staff was interviewed and confirmed that part time LVN was hired and medication refill procedure was reviewed. See follow up inspection, 4062259.


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

raw_content: Two children in care stated they were not provided their prescribed inhalers when they requested from staff due to having breathing issues.

Correction Narrative: On 05.07.25 a follow up inspection was conducted in person. Staff was interviewed and confirmed that medication refresher training was completed. Documentation was obtained for all those who attended the meeting. See follow up inspection, 4055588.


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

raw_content: Two (2) children in care were in a locked bedroom and engaged in sexual activity that resulted in the outcry of sexual assault.

Correction Narrative:
On 2/27/25 a follow up inspection was conducted in person. Staff was interviewed and confirmed that supervision issues were addressed during staff meeting regarding supervision. Documentation was obtained for all those who attended the meeting. See follow up inspection, 4045013

On 02.12.25, the operation provided the following corrective action:

Corrective Action:
1. The Residential Supervisor will meet one-on-one with the involved staff by 2/13/2025 to review the findings of the investigation and reinforce best practices for youth supervision and intervention.
2. During our next team meeting (tentatively scheduled for 2/24/25), staff will receive additional training on recognizing subtle signs of concerning behavior and best practices for intervention, even in instances where direct auditory or visual indicators may not be present.
3. Leadership will review current policies regarding locked doors to determine if adjustments are needed to balance safety, security, and prompt intervention.
4. Going forward, any youth on safety plans with increased supervision will be required to keep their doors unlocked and open during waking hours.


summary: 745.8411(b)(3) - Responsibilities - Provides access to all records

raw_content: The operation failed to provide all serious incident reports related to the allegation being investigated.

Correction Narrative: On 03.13.25 a follow up inspection was conducted in person. Staff was interviewed and confirmed that records issues were addressed during staff meeting regarding records. Documentation was obtained for all those who attended the meeting. See follow up inspection, 4047219


summary: 748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training

raw_content: The operation provided compliance on 10.28.24 stating they will handwrite the missing information by 11.15.24. As of 11.19.24 this has not been completed, and training certificates are missing the name and qualifications of the instructor.

Correction Narrative:
The chief residential officer provide compliance via email on 11.22.24:

1.	The Chief Residential Officer (CRO) developed a new certificate with a coding feature to automatically include the trainer's name, which has been assigned to all future Connections training in Relias. However, this certificate will only apply to upcoming training completions, so changes must be handwritten on previously completed ones. Additionally, the certificate must be manually selected each time it's printed from Relias.
ii.	To correct our mistake from last time, we have assigned the following tasks with due dates:
1.	For trainings already completed, we must handwrite the missing information. This will be completed by 11/24/2024 and was assigned to our overnight Supervisor Latasha Vaclavik to begin on 11/21/24.
2.	The Program Manager Tanya Paniagua will complete an audit of all training certificates to ensure each document has been corrected to reflect the standard referenced above on 11/25/24

The operation training certificate audit and a sample was provided via email on 11.29.24. The audit details information about all certificates having instructor names, credentials and if any corrections are still needed.

An administrative review was requested during the 10.22.24 inspection for this citation.


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 the inspection, one pill of Benztropine medication was found outside the container and inside the Ziplock bag where the medication bottles are stored.

Correction Narrative: Medication storage was reviewed and all medication was found to be stored in their original containers.


summary: 748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them

raw_content: Residential Child Care Regulation observed the living area without any evacuation plan. The operation printed and posted the evacuation plan during the inspection.


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

raw_content: The employee file reviewed has delinquent training related to Normalcy.

Correction Narrative: The employee completed the Normalcy training on 09.11.24


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: The employee file reviewed has delinquent training related to transportation.

Correction Narrative: The employee completed the transportation training on 09.11.24


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

raw_content: During the walkthrough of the facility, it was observed that an occupied bedroom did not have a required waterproof matress or cover.


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

raw_content: The employee file reviewed has delinquent training related to Trauma Informed Care.

Correction Narrative: The employee completed the Trauma Informed Care training on 09.11.24


summary: 748.2205(2) - Medication label error-Have the label on the medication container corrected as soon as possible, but no later than the next business day

raw_content: Medication label does not reflect the dosage increase as indicated on the prescription.

Correction Narrative: The operation informed the medication label was correct due to the number of pills the child was required to take, this would meet the appropriate dosage. AR will be requested.


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

raw_content: The medication count was documented incorrectly on two child medication logs.  There was also conflicting information documented on the incident report when compared to medication logs.

Correction Narrative:
On 06.20.24, the operation provided compliance for the above noted citation via the Administrator. Below is the operation's corrective actions:

Corrective Actions:
1. The operation are continuing supervisory medication audits every morning, M-F and have another staff assigned to audit on Sundays.
2. The Residential Supervisor is now tracking medication errors per staff.
3. Staff member who conducted the majority of the medication errors over the weekend, has been administered disciplinary action.
 a. Additionally, the staff has been removed from medication administration until he/she attends
 another medication training within the next 2 weeks.
4. Effective immediately, the staff members on shift will carry out the following procedure:
 a. Bring all the youth to the common area for TV/movie and/or a table activity during medication
 administration times
 b. The staff member assigned to administering medications will administer medications 1 youth at
 a time, until all youth have received their medication.
 c. A 2nd staff on shift will conduct a second medication count within an hour of the medication
 administration
 d. After all medications are administered and 2nd counts are completed, staff on shift will email
 the shelter's leadership including the Residential Supervisor, Program Director, and Chief
 Residential Officer to notify the procedure has been completed and whether any issues occurred.
 e. The shelter leadership will rotate oversight of these emails and address any concerns
 immediately.


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: A child in care was administered  another child's  prescribed sleep medication.

Correction Narrative: The operation completes Supervisory medication audits every morning, documented on the bottom of medication logs. The staff deemed responsible for majority of the medication concerns completed an updated medication training on 06.21.24. A new medication procedure was rolled out on 06.21.24 and the operation reported this is holding staff accountable, but there is still room for improvement.


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

raw_content: Three children in care were not given medication as prescribed.


raw_content: The incident report for a child in care s self-harm attempt was altered by operation staff during the inspection, minimizing the severity of the situation.

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

Correction Narrative:
The operation provided compliance via email on 05.23.24. Compliance is as follows:

Response:
Our goal is to accurately reflect the events of all incidents. We did not minimize the severity of the situation. The original language in the document was inaccurate based on the communication between our leadership and staff during the incident, which contradicted the writing in the original language. Our changes to the document effectively made it more accurate.

Corrective Actions:
1.We have created an addendum option in our incident reports for adding updates to incident reports.


raw_content: A child in care was not given medication as prescribed.

Correction Narrative:
Regarding the medication error:
a.The supervisor audits will be done first thing when the assigned leader arrives (HM visits will no longer disrupt these audits);
b. Any missed medications will be delivered to the youth and given; and,
c. Progressive disciplinary action will be used when necessary.
This was this employee's first time making this mistake.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: The operation failed to provide the supervision required for a staff member's conditions on their eligibility to be present at the operation.A staff member  with conditions was allowed to be alone in a room with the child in care, while the supervising staff remained in their office.

Correction Narrative:
Deficiency on Standard 745.635(3) AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions. (Weight: High)

The operation failed to provide the supervision required for a staff member's conditions on their eligibility to be present at the operation. A staff member with conditions was allowed to be alone in a room with the child in care, while the supervising staff remained in their office.

Response:
I believe this is just a misunderstanding of semantics. The staff member in question is never left alone to supervise youth in our shelter.

Corrective Actions:
1.Regarding the employee with provisional conditions:
a.The supervisor will meet with the employee to reiterate the conditions of her eligibility; and,
b.The LCCA met with shelter leadership via phone on 5/9 after hearing about the citation to retrain on the employee's conditions.

Additional in-person follow-up was conducted on 05.22.24 for inspection #4001131. The operation touched based with leadership to ensure they are all on the same page regarding background check conditions. The operation informed they meet with the employee to reiterate what her duties are to be. The operation reported the employee was not left alone with children in care.


raw_content: One child's medication record had a missed dose on two medications due to the child having an appointment. Two other children had one missing dose documented without a reason.


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

raw_content: Two children had medication records without the time of administration documented for one dose.

Correction Narrative: Compliance met.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: While reveiwng 1 of 5 child medication records, it was observed that a child's refusal of a presribed medication was not documented as a medication error.

Correction Narrative: The administrator provided compliance this date via email. The administrator reported the supervisor will continue doing their medication audits; if any medication errors are found, they will provide appropriate disciplinary action as needed. They will also ensure documentation is complete. Employees will be addressed if incident reports are missed, patterns will lead to disciplinary action.


summary: 748.941(d) - Training Criteria-A health-care professional or a pharmacist must lead the training in administering psychotropic medication.

raw_content: While reviewing the training record of an employee, it was observed that the staff has not recieved administering psychotropic medication insturction from a  health-care professional or a pharmacist.

Correction Narrative: The administrator provided compliance this date via email. The administrator reported the operation will hire a healthcare professional for future trainings within the next 45 days. The operation will send staff to train with the new healthcare professional once they are hired/contracted.


raw_content: While reviewing one (1) employee record, it was observed that the employee does not have the total hours required for transportation training.

Standard Number / Description: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

Correction Narrative:
On 04.11.24, the operation provided compliance for this noted citation. The operation reported they do conduct transportation training for two (2) hours, however, during this review it was found that the training certificate incorrectly listed the training for one (1) hour, which was a clerical mistake and has been corrected.

The operation reported the staff received his additional one (1) hours of transportation training on 03.28.24. The updated transportation certificate was provided.


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: The operation failed to notify licensing of a physical altercation between children in care, where law enforcement responded and citations for all children involved were given

Correction Narrative:
On 07.05.24, The operations administrator provided a corrective action plan for the above noted citation:

Corrective Actions:
1. The operation will call the DFPS Hotline for every Serious Incident as they apply per Minimum Standards.
2. The operations process for notifications is as follows:
    a. Staff call the On-Call Supervisor if one is not present during the incident
       i. On-Call Supervisor notifies the Chief Residential Officer (CRO)
          1. CRO notifies the CEO.
    b. While these notifications are in process, the CRO works with the On-Call Supervisor to ensure everyone's safety and coordinate action to bring the
       situation under control if it is not resolved by the time On-Call is notified.
    c. Once the situation is resolved, the CRO works with the On-Call Supervisor to ensure the DFPS Hotline, DFPS Caseworkers, and DFPS Residential
       Contract Manager are notified of the incident within the required timeframes. The Hotline Report info is provided in the following email
       notifications:
       i. The Program Director, CRO, and CEO are all copied on notifications to the DFPS Contract Manager
       ii. The Program Director, Residential Supervisor, and CRO are all copied on notifications to the DFPS Caseworker.
3. Lastly, the operation will provide training to residential staff on this standard by 7/19.
    a. This training will cover the standard and a debrief of the reason for the citation.


raw_content: The Serious Incident Report provided by the operation contained an inaccurate date in the Agency Notifications section and a staff member who was present at the time of the incident was not included as a witness.

Correction Narrative: The administrator provided compliance this date via email. The operation reported during future reviews of incident reports, they will focus on date and witnesses more. The operation informed this is not a pattern and is very unusual for them to miss. The supervisor will discuss the incident report date and witness issue during the next supervision with the staff that authored the incident report.


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

raw_content: While at the operation to conduct a heightened monitoring inspection, it took the operation two (2) hours to provide requested documents.

Correction Narrative:
An email was received by the administrator to address compliance for the citation issued. The operation reported on 02.06.23 the Chief Residential Officer and Chief Executive Officer met with the Heightened Monitoring team to discuss the expectations promoted by the HM team and will be scheduling a meeting with HM supervisor.

The operation will continue to get documentation to monitors as quickly as possible, and cell phone number of leadership team members will be provided to HM representatives so if any delays are perceived, those can be corrected immediately.

The operation will request a timeframe from each monitor during each visit to ensure duplication of case records is done within a reasonable time frame.


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

raw_content: Child in care reported having continued pain and discomfort, however, was not taken to see medical provider until the following day resulting in condition worsening.

Correction Narrative:
On 02/06/24 the administrator provided a response to Heightened Monitoring Inspector withe the following corrective actions:

1.The Chief Residential Officer will ensure continued compliance with medical care for youth.
2.Connections will continue to document youth refusals of medical care in incident reports as we had done for this incident.
3.Connections will go through the Administrative Review process as Connections was in fact compliant by offering the youth opportunities to see a medical professional, which the youth refused.


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

raw_content: During walk through of the physical site it was noted that the backyard fence had broken plans and exposed nails. One of the toilets was observed to have a toilet seat that was too small for the toilet bowl. Metal grate in hallway is broken and dented exposing sharp edges.

Correction Narrative: Inspector received photographs on 10/2/2023 showing metal grate in hallway was secured and no longer unhinged, a toilet that fits the toilet bowl in the restroom, and fence repaired.


summary: 748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents

raw_content: Two child records did not have documentation of providing advance notice of service plan staffing to guardians.

Correction Narrative: Compliance plan received on 9/28/2023 stated the Chief Residential Officer will meet with shelter leadership to determine the best way to upload proof of 14-day service plan notices to our electronic record system. Inspector received email from operation on 9/28/2023 with copies of 14-day notifications for missing files.


summary: 748.1543 - Immunizations - must have accepable documentation

raw_content: One child file did not have immunization record or proof of TB test.

Category: Child Care

Correction Narrative:
Compliance plan received on 9/28/2023 from Administrator stated in response to citation an administrative review would be requested as they feel they were unjustly cited during monitoring inspection.
Inspector received an email copy of immunization record for missing child record on 9/28/2023 obtained from New Braunfels ISD.


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

raw_content: One of the mattresses was noted to be dirty and stained.

Correction Narrative: Compliance plan received on 9/28/2023 from Administrator informing of previous mattress being switched out on 9/25/2023 after monitoring visit, however a picture was not provided of new mattress until 10/2/2023.


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

raw_content: While reviewing menu for the last 90 days it was noted that snacks items were not listed.

Correction Narrative: Inspector received email on 9/28/2023 of with a copy of the updated menu from operation listing what snacks were being offered to children in care.


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

raw_content: Staff did not properly intervene between children in care.

Correction Narrative: Inspector received email from LCCA informing of staff training to be conducted the week of 9/11/20233 thru 9/15/2023.  LCAA will submit training certificates and/or sign in sheet by 9/18/2023. Inspector received staff sign in sheet for de-escalation training dated for 9/11/2023.


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

raw_content: Caregiver admitted to dealing with another situation at the outing and not being aware of two children in care thus leading to inappropriate behaviors between the two children.

Correction Narrative:
1)	The Program Manager will update future service plans to better explain our level of supervision effective immediately.
2)	Shelter Leadership will host next staff meeting by end of month. It is currently scheduled tentatively for 8/22/2023.
a.	One topic for this meeting will be how to provide supervision to youth during supervised outings when they have a behavioral plan in place.
3)	Shelter Supervisor will meet with Youth Empowerment Specialists next supervision to cover being aware of youth on Behavioral Intervention Plans (BIPS).

Inspector received staff trainings for 8/23/2023


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

raw_content: A child in care was improperly restrained by staff members.

Correction Narrative: Inspector followed up with staff regarding deficiencies and was able to determine staff were retrained and were made aware of new policies put in place to mitigate the risk to children in care.


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

raw_content: Identified high risk behaviors do not include plan to address the risk for children in care.

Correction Narrative: Inspector reviewed compliance plan and two service plans and found that high risk behaviors had information detailing how operation was addressing them with the child and plans to reduce risk of behaviors from occurring in the future.


raw_content: A staff member provided children in care with vape pens.

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

Correction Narrative:
Compliance plan and certificates of staff training received on 7/26/2023. All Youth Empowerment Specialists are required to complete a number of trainings covering topics such as
recognizing and reporting various types of abuse, ethics and boundaries, serious incidents, and on-call procedures
(reporting) as part of a pre-service curriculum before being allowed to work with children as a caregiver in ratio.
2) These training topics are retrained via the DFPS training hub, other online trainings, and by the Supervisor or
Program Manager annually, or more often as needed. These training courses are often covered in staff meetings as
well:
a) A staff meeting was held to debrief the incidents related to this citation and retrain staff on reporting abuse,
boundaries, supplying illegal substances, and serious incidents.
b) All staff were trained on the aforementioned topics on June 6th and certificates of completion were provided to
our RCCR Rep.
3) The Residential Supervisor will debriefed the training with each Youth Empowerment Specialist during their biweekly supervisions to address any questions or concerns they had since the training.
4) Residential Counselor and the Youth Success Coach facilitated a group with our residents on boundaries with staff
and red flags to bring to the attention of a trusted staff member or member of leadership. Topics included:
a) What information staff members should and should not share with youth;
b) The dangers of accepting illegal substances from adults in general; and,
c) What to do if they come across a staff crossing boundaries.
d) This group occurred June 7


raw_content: During this investigation it was confirmed staff had an inappropriate relationship with a child in care. This same staff was aware of a child self-harming and did not report to hotline or other staff present to ensure the safety of the child. Additional staff involved were found to have provided child in care with illegal substances.

Correction Narrative:
On 06/23/23, on-sight inspection follow-up was completed to ensure all training has been completed and speak with staff to ensure they are aware of their requirements moving forward. No concerns noted, operation is in compliance.

Certificates for staff trainings received on 6/19/2023

On 05/26/23, compliance plan was received from the operation by email. The following corrective actions were put in place: Administrator provided staff completed DFPS trainings

1)	At the time of the incident, Residential Leaders held an emergency meeting immediately after the allegation was made to gather evidence:
a)	Residential Leaders notified the hotline as well as all appropriate parties;
b)	Residential Leaders held an emergency meeting/debrief with the CEO and Chief Human Resources Officer to terminate the alleged perpetrator within the same hour the allegation was made; and,
c)	The employee was immediately terminated.

2)	All Youth Empowerment Specialists are required to complete a number of trainings covering topics such as recognizing and reporting various types of abuse, ethics and boundaries, serious incidents, and on-call procedures (reporting) as part of a pre-service curriculum before being allowed to work with children as a caregiver in ratio.

3)	These training topics are retrained via the DFPS training hub, other online trainings, and by the Supervisor or Program Manager annually, or more often as needed. Additionally, these training courses are often covered in staff meetings:

a)	The next staff meeting will debrief the incidents related to this citation and retrain staff on reporting abuse, boundaries, illegal substances, and serious incidents.
b)	This staff meeting will occur by June 9th.

4)	The Residential Supervisor will debrief the training with each Youth Empowerment Specialist during their next bi-weekly supervision to address any questions or concerns they've come up with since the training.

5)	Residential Counselor and the Youth Success Coach will facilitate a group with current residents on boundaries with staff and red flags to bring to the attention of a trusted staff member or member of leadership. Topics will include:
a)	What information staff members should and should not share with youth;
b)	The dangers of accepting illegal substances from adults in general; and,
c)	What to do if they come across a staff crossing boundaries.
d)	This group will occur by June 9th.

Due to training not being completed until the 9th of June this was approved by RCCR Supervisor, for extension. Extension was granted on 05/30/23. New letter with comply by date of 6/12/23, was sent to operation.


summary: 748.3443(a)(2) - Food Preparation-Food items must be stored on clean surfaces

raw_content: Refridgerated food was not stored on clean surfaces.


raw_content: Staff involved was not aware children in care went into the laundry room alone and was observed on camera to not be supervising children in care.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: The boys' bathroom shower was dirty during walkthrough of operation.


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: Boys' bathroom did not have soap accessible to them.


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

raw_content: One resident was laying on their bed without a mattress cover.