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

raw_content: During the inspection of girls bathroom, the hot water handle on the 1st sink to the left did not turn on water. There is a potential leak  under the sink area as there was water on the floor under sink extending to the first two toilets in girl's bathroom.

Correction Narrative: On 1/27/25, the Director of the operation reported that they spoke with the licensing representative on this investigation on 1/16/25 regarding the deficiency related to the plumbing issues in one of two bathrooms. It was reported the problem was first reported to them on Friday, 1/10/25 and their maintenance team responded immediately and temporarily addressed the issue, but parts had to be ordered for a permanent fix. Once the parts arrived, maintenance completed the repairs later that same day, after the licensing rep on the inv. had left the facility. The Director reported they contacted that rep to inform them that the issue had been resolved, and that rep requested the maintenance ticket. The ticket was sent to that rep at 2:17 pm on 1/16/25. The operation is requesting an admin review for this deficiency.


state: TX

facility_name: LifeWorks Emergency Shelter

summary: 748.685(d)(1) - Caregiver responsibility- Child participating in unsupervised activity - caregiver must know where child will be

raw_content: Children are being allowed to leave the facility and are unaware of where the children are at or are going. Children are remaining gone for hours at a time without a check in with staff or staff checking on them.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: In response to these deficiencies, the Director reported they have organized an all-staff training to review supervision expectations both onsite and offsite. Additionally, they updated and attached their emergency shelter manual policies/procedures, specifically section 5, to reflect the expectations for youth supervision. The Director reported they have also met with their case managers (CMs) to discuss and clarify the licensing expectations for service plans. They have since made significant progress in ensuring their service plans meet the required standards. The Director reported they will continue to support the CMs through follow-up emails, case staffing, and regular supervisions to review each new youth and their service plans. The Director reported they are hopeful that the follow-ups and training initiatives will continue to support their efforts in reaching the standards in providing the highest quality care for the youth in their program.


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

raw_content: In reviewing the Service Plans for both children a general statement was given and not specific details for each child.


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: Citation: The child did not return to the van at 9:45PM when planned with staff. This report was not made to the hotline until 1:34AM, roughly 3.5 hours after the incident occurred. With the child's sex trafficking history the incident should have been reported immediately.

Standard Risk Level: Medium

Correction Narrative:
An email was received on 1.17.25 from the operation. The operation reported expectations and requirements are communicated with staff during weekly case staff meetings and via email regarding contacting licensing immediately following police contact when they have suspected human trafficking concerns. They also reported the requirement has been added to their policies in their shelter manual and they will continue to train all new staff of this policy moving forward. They additionally reported they are working to schedule an all-staff training to give clarity on reporting future incidents and timeframes.

On 1/21/25, the assigned licensing representative sent the operation an email asking them what date they have scheduled the all-staff training. It was requested they provide the date this is completed or will be completed and a copy of the staff signatures who attended the training be provided as well. The operation replied that a Supervisor and the Director are working on scheduling the all-staff meeting for late February (2025).


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: It was found that operation staff had suspicion of several residents shoplifting/stealing from different stores in the community and bringing a variety of contraband back onto to campus, to include alcohol/illegal substances and other items, for some time, however the operation failed to create safety plans for the children to address these concerns.

Standard Risk Level: High

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


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

raw_content: During the course of the investigation, it was reported that multiple residents have brought contraband and used contraband on campus.


summary: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

raw_content: It was found that during a search conducted by staff in a child's room at the operation on 11/5/24, two THC pens, a vape pen, one lighter, and four empty boxes of THC related products were discovered. Staff also found a razor, one pair of scissors, and Tylenol as well.

Correction Narrative:
On 12/2/24, the Director reported that they keep in constant contact with the children's case workers to discuss safety plans and placement options and notify them of every incident and concern that they may have.

On 12/4/24, the assigned licensing representative for this operation had a discussion by phone with the Administrator and the Director regarding this deficiency and the contraband concern that should addressed by the operation.

On 12/5/24, the Director reported they will be working with the Case Manager to discuss on-going service planning to address high-risk behaviors. The Director also reported that their room search plan is that staff will start to complete room searches at least twice a month. Day shift will complete room searches between the 1st-10th and evening shift will complete room searches between the 15th-30th of each month. These searches will be documented, and they will be updating their policy in their shelter manual to reflect this new change.

On 12/13/24, the Director created safety plans for children in care who the operation had concerns about regarding bringing either illegal substances, tobacco, and/or alcohol on campus. Children were searched on this day by a staff upon them coming back from off campus to ensure no contraband was being brought onto campus. During an inspection on 12/13/24, this licensing representative observed this being done with four different children who returned from the community, and they were cleared as no contraband was found on their person.


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

raw_content: During the walkthrough of the operation an uncovered bowl of cheese was observed in a refrigerator. [

Corrected at Inspection: Yes


summary: 748.705(b)(8) - Reasonable & prudent parent standard-must consider the outside supervision of the activity, if available and appropriate

raw_content: A child was dropped off at an unknown person's home by staff.

Correction Narrative: The Administrator stated that they have put several new processes in place regarding the unauthorized absences of children at the operation and one process involves utilizing safety plans and working with the CPS caseworkers to ensure that the child's high risk behaviors are documented and there are protocols put in place for those high risk behaviors. The Administrator sent an email to the assigned licensing representative wanting to follow up and ask one question in regard to the deficiency. The Administrator states in the deficiency it references dropping off children at various locations and the recommendation being for them to keep record of who they drop children off with. The Administrator reported for this incident regarding an unauthorized leave (UL) for a child, the UL documentation notes that the child left the operation on their own accord and was not dropped off at an unknown location by staff. The Administrator wanted to check to see if the incident was accurately reported and that the UL documentation shared was properly understood. Admin review was requested.


summary: 748.363(5) - Personnel records-Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position.

raw_content: During the inspection, it was found there was documentation missing for the staff's qualifications.

Category: Reports and Record Keeping

Correction Narrative: The operation Division Director of Emergency and Transitional Housing sent an email on 9/20/24, reporting that the staff member who did not have their education verification has sent in verification of their High School Diploma. The operation Division Director also reported that they and the Administrator have spoken with their HR team about gathering documentation to verify the education status of all shelter staff upon hire. Their HR team is planning to do a self-audit to ensure that they have education verification for all current staff, or any required professional licensures, certifications or registrations, required for their position. The operation Division Director also attached the high school diploma for the staff file that was evaluated to be missing this for proof of verification of education.


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

raw_content: During the inspection it was found that the background check for the operation's current CEO as of July 1, 2024, has been inactive and their former CEO's background check was also inactive prior to 7/1/24.

Correction Narrative: On 9/11/24, the operation reported by email that they have gotten in touch with their HR to ensure they get the proper background check (BGC) completed. The also sent an email to their CBCU representative (rep) to gain clarification regarding BGCs and CBCU informed them of the requirements. On 9/13/24 the operation sent an email reporting their current procedures include that all shelter staff, volunteers, and interns are subject to complete a background check in accordance with Minimum Standards/TAC. On 11/6/24, an in-person follow up was conducted to verify that the CEO's background check had been completed. This was cleared on 9/16/24 once it was run after the previous inspection on 9/10/24 and is in compliance.


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

raw_content: During the inspection, it was found that two child files were missing another method of identifying the child.

Correction Narrative: The operation Division Director of Emergency and Transitional Housing sent an email on 9/20/24 to their assigned licensing representative, reporting that they emailed their entire facility team with notification of this minimum standard requirement and what the specific findings were during the monitoring. It was communicated that all children need to have a client ID included on the front of the child file and on the top of the Client Demographic Form, which is at the front of the child file. They reported they have established a plan to use the Client ID number as the standard identifying number that they can use, since all residents at the facility will have a unique Client ID that they can use to differentiate and identify each child. They have also held a specific meeting with their YCW Lead AM staff member who is the primary staff responsible for completing and reviewing all child files after intake. In this meeting they also updated their Intake Packet Cover Page as well as their Demographic Form to be more specific in requesting the Client ID. On the Intake Packet Cover Page, they reported they have listed the Client ID to be written underneath the child's name. On the Demographic Form, they have edited the document to request the Client ID to replace what used to be labeled Case #.


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

raw_content: During the inspection, it was found that the psychotropic medication training for one staff file was not led by a qualified health care professional.

Category: Training and Professional Development

Correction Narrative: On 9/20/24, the Division Director reported they have sent an email to their entire shelter team that they are going to review their onboarding process as it relates to training the administration of psychotropic medication. The Division Director reported their Chief Operations Officer has also begun reaching out to health-care professionals in the community to provide instructor-led training for when they have new hires. They also reported theyve communicated with their HR team that they are required to have instructor-led training on administering psychotropic medication from a health-care professional or pharmacist. They reported they will track and document this training as new employees onboard.


summary: 748.461(1) - Unauthorized Absence-Triggered Review must include review of childs records abt previous unauth absences, including previous debriefings

raw_content: The triggered reviews for 3 children did not have details about the unauthorized absences which triggered the review and did not explain prior debriefings with the child.

Correction Narrative: An email was received by the operation on 8.27.24. It was explained a meeting was held with the Case Manager and Youth Care Worker Supervisors to discuss the deficiency and review the standard. Supervisor will make debriefings electronically available via Teams for easy retrieval.


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

raw_content: On 6/14/24, during the walkthrough, a nail clipper (considered as contraband), was in a child's room. This has been cited two other times in less than 3 months.


summary: 748.453(a)(4) - Unauthorized AbsenceAnnual summary log must include name of caregiver responsible for child at time absence discovered

raw_content: The unauthorized absence log documented the staff who reported the incident to the hotline instead of the staff responsible for the child at the time of the incident.

Correction Narrative: An email was received from the operation on 6.13.24. It was explained the Unauthorized Absence Log was revised and backdated to 6/1/2024 to include the staff responsible for the child at the time of the incident instead of what was previously recorded. Emergency Shelter Supervisors reviewed the changes with their direct reports. The Director of the Emergency Shelter demonstrated proper use of the log during our team meeting on Tuesday, June 4th and a virtual staff check-in meeting was held on 6/13/2024 to answer questions or provide coaching.


raw_content: The triggered review did not have details about the previous 4 unauthorized absences and did not explain prior debriefings with the child.

Standard Number / Description: 748.461(1) - Unauthorized Absence-Triggered Review must include review of childs records abt previous unauth absences, including previous debriefings

Correction Narrative: An email was received from the operation on 6.13.24. The Emergency Shelter Director reviewed the deficiency with Case Manager responsible for completing all client Triggered Reviews. Scheduled meetings will occur moving forward to thoroughly review and ensure Triggered Reviews include prior briefing information, the causes and resolution of unauthorized absences, and trends observed. Requirements shared by CCR Representative provided support. The operation will refer to the standard for continued clarity.


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

raw_content: During the follow up inspection, a broken cylindrical glass tube was observed by licensing on the floor of a child's room that had not been discarded. Staff had not been aware of this. This was corrected at inspection.


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

raw_content: Through interviews and documentation, it was determined that a primary caregiver could not physically intervene and stop in altercation.

Correction Narrative: On 4/23/24, the assigned licensing rep conducted an unannounced inspection and there were no concerns noted relating to this standard. It was reported by children and staff that staff intervene and react properly when incidents occur.


raw_content: Through documentation and interviews it was determined that staff was aware that residents liked to collect items from the community and bring them back into the operation. Items considered contraband were found in a resident's room.

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


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: A child in care left the operation and a report was made almost 3 hours after required timeframes.

Correction Narrative: The operation has spoken with staff and shift supervisors in regard to the needs of reporting timely.  This was completed over 2 days.


summary: 748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities

raw_content: After reviewing 1 child file, it was found that the recreation section in the service plan was missing.

Category: Admission, Service Planning, Discharge

Correction Narrative:
Following the unannounced visit on 9/20/23, Lifeworks Shelter Director met with Shelter Case Manager to discuss the deficiencies received. The Director and Division Director have reviewed the following deficiency and addressed it in the following way:

The operation reported all LifeWorks shelter clients follow a daily schedule and programming designed to respond to their needs and individual goals. The facility's recreational activities and outings are designed to offer youth activities that focus on Educational, Self-Care, Physical/Active, Arts and Crafts, Entertainment, and Outdoor. Youth are also encouraged to share ideas and suggestions they have for recreation by completing an Activity Request Form'. LifeWorks Shelter Director met with the program's Case Manager (CM) to discuss the expectation of notating all plans for social, extracurricular, recreation, and leisure activities in each child's service plan. To ensure compliance with this standard, all service plans will be reviewed and audited for completion by the Director and CM prior to signing. Additionally, to ensure that the recreation section is not missed or left empty, the CM will reference planned activities scheduled for the week/month and notate any and all that the child shows interest in participating in. If none are identified, the CM will provide the child with the Activity Request Form' that can be completed together and documented in their service plan.


summary: 748.313(3)(E) - Serious Incident -Unauthorized absence of a child if child returns to op after 24 hrs document as addendum to report documenting childs return

raw_content: It was found that there was no communication log for the child/victim for after this child left the facility on 7/2/23 at 10:00 pm. There was no update on whether the child returned to the facility.

Correction Narrative: On 9/8/23, the operation reported LifeWorks' Emergency Shelter staff are instructed to update all documentation when youth return to the operation including their condition upon return, debrief of the incident and any restrictions applied moving forward. Staff also notify managing conservators of the youth's return and cancel APD reports as needed. As a result of the deficiency, Shelter Director met with Youth Care Worker Supervisors to include a communication note section to the Unauthorized Leave (UL) form in order to provide updates of the youth's runaway status including attempts made to contact youth, youth contacting the shelter while on runaway status, and/or any notes relating to the youth's runaway status. An updated UL template form was provided with follow up response.


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: It was found that on 6/24/23, the operation received a screenshot of an inappropriate text message sexual in nature sent to them by a minor resident at the facility that had received the message from a young adult resident there, however the operation didn't see the screenshot until 6/30/23 and then called this into the A/N hotline upon discovery. It is unknown if the text message was sent to the minor resident on or off campus.

Correction Narrative:
On 9/8/23, the operation reported all LifeWorks shelter clients are provided with the Emergency Shelter number at intake and again when completing orientation. The number is also posted in the milieu for quick access. Clients are also encouraged to call anytime (24/7) while in the community, if they encounter any danger and/or feel unsafe. The operation reported if a client does not have a phone or an active phone plan, LifeWorks can provide one and unfortunately, this client alerted a staff of the inappropriate texts while this staff was out of the office and
the messages were not seen until days later. To avoid incidents such as these in the future, LifeWorks' Shelter Director will monitor work phones assigned to Emergency Shelter Case Managers when they are out of the office or on leave. Case Managers will notify all shelter clients when they are unavailable and/or out of the office. Case Managers will also encourage clients to speak with Emergency Shelter staff regarding any concerns, requests, and/or inquiries during their absence.


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: After reviewing documentation, it was determined that the operation reported to the hotline 2 days after the UA occurred.

Correction Narrative: An email was received from the operation. Upon receiving the conclusion letter for investigation #3006878, Lifeworks Shelter Director met with Youth Care Worker shift supervisors to address the deficiency received. It was discovered that the oversight was a result of the youth's constant in/out presence at the shelter and runaway status. We determined that our notification practices needed to be reinforced and sent an email to the entire team with instructions and reporting expectations. To ensure that all serious incident reports are reported in a timely manner (no later than 6 hours after determining an unauthorized absence of a child), we relabeled our filing system to create a more streamlined process of notification. This was followed up by a team meeting on 7/6/2023 and provided additional support and coaching to staff.


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

raw_content: During this inspection, it was found that one bedroom (#7) had clutter and lot of other belongings thrown around the room to which could pose a safety hazard. There was also a ceiling fixture in bedroom #2 that needed repair and a towel rack in the bathroom of bedroom #5 that also needed repair.

Category: Physical Site

Correction Narrative: The operation reported that the Lifeworks Shelter Director met with Youth Care Worker shift supervisors to address the clutter in room #7. With the assistance of staff, child was able to clean and organized their room/bathroom (see photos). They've established incentives in the past for child(ren) productivity. However, they have started implementing monetary incentives upon a child cleaning their room with the hopes that they feel motivated to keep their space tidy. Youth Care Workers working the evening shift will block out time to assist child(ren) with deep cleans and document when they are completed. Case Manager and Director will meet with the child(ren) and issue action plans if bedrooms are not in compliance with the minimum standards. Lastly, maintenance requests were submitted and completed for the ceiling fixture in room #2 and the towel rack in the bathroom (of bedroom #5). Photos provided. Additionally, all LifeWorks Emergency Shelter staff are expected to report and submit any maintenance requests should any furnishings or facilities need repair. During hourly room/perimeter checks, Youth Care Workers will ensure that common spaces are clean and safe. The evening staff will schedule time with children to assist with deep cleans in order to maintain a clean environment.


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

raw_content: During the inspection, the TB test results, driver's license record, Affidavit for application of employment, and drug tests results were not available for review for two of two staff files.

Correction Narrative: Following the 9/28/22 visit, Lifeworks Shelter Director met with Human Resources Director to go over the requirements in relation to this standard. HR continues to complete and oversee the onboarding process for all LifeWorks staff and are responsible for storing paper copies of TB test results, driver's license records, Affidavit for application of employment, and drug test results at Lifeworks' South location at 3700 S. 1st Street. These records are currently in the process of being uploaded electronically and will be shared with the Shelter Director via Microsoft Teams. HR Director confirmed that Shelter staff files can be prioritized so that information can be readily available in the future.


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: During the inspection, it was found that two children were not administered their prescription medication(s) on 9/24/22 and 9/25/22 and one of the two children also wasn't given their prescription medication on 9/27.

Category: Medication

Correction Narrative: Following the 9/28/22 visit, Lifeworks Shelter Director met with Youth Care Worker supervisors to go over the requirements in relation to this standard. They identified that the best way to move forward would be to retrain current staff on their medication procedures and ensure that they are properly documenting when medications are/are not dispensed (including reason). The operation Youth Care Worker III has met with primary medication staff to address errors from dates listed above. A Medication and Documentation refresher training has been scheduled for 10/9/22, 10/11/22, and 10/29/22 from 10:00am  12:00pm.


raw_content: A unauthorized absence of a child in care was reported 4 hours after the required timeframe to Licensing.

Standard Number / Description: 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.

Correction Narrative: An email was received on 11.7.22 from the Shelter's Director. The Director explained she met with supervisors and staff to discuss the UA. It was mentioned there was initial confusion surrounding the child's discharge status and the staff responsible for initiating the UA did not do so. The staff responsible no longer works at the operation, effective 9.27.22. Communications were sent to staff to reiterate documentation procedures and reporting timelines.


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: After reviewing 5 out of 5 incident reports, it was observed that there was no documented resolution or follow up of the incident.

Correction Narrative:
An email was received from Yuri Cueto stating the following: Following the report received on 6/24/22, Lifeworks Shelter Director met with Case Manager, Kevin Lankford and Youth Care Worker III's to discuss the TA received. Case Manager's are tasked to document updates, summary of conversations, and outcomes on all client IR's. To ensure that documentation is
readily available and consistently updated, Youth Care Worker's will also include their notations and follow-up interactions with clients. Youth Care Worker's already have conversations following incidents, complete safety plans, and document observations in shift notes to share with the rest of the team. Case Manager will continue to schedule follow-ups after a serious incident has occurred and should the client be unavailable, a shift supervisor (YCW III) will attempt to follow-up with said client in the evening, overnight, or weekend shift. Shelter Director will also ensure that a resolution is clearly stated on the incident report prior to signing and filing.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: Through the course of the investigation, it was discovered that a child in care performed a restraint on a peer. Staff verbally tried to stop the restraint that started in a physical fight but did not physically try to stop the restraint that lasted approximately a minute.

Correction Narrative:
Operation sent the following compliance plan. "Shelter Director met with agency EBI certified
instructors and Youth Care Worker III's to discuss the TA received. A scheduled refresher training
for all shelter staff will take place on June 10th and 13th. This refresher will be mandatory and will cover the physical portion of our chosen EBI (Handle with Care). We will also incorporate scenarios including the one that occurred in order to provide staff will clear guidelines and expectations during client altercations. We will continue to request that staff communicate observations and interactions with clients in Shift Notes (completed on every shift) that inform Emergency Shelter staff of observed tension, incidents, and clients that are need of additional support and/or supervision"


summary: 748.303(a)(9)(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: The unauthorized absence of a youth in care at the operation was reported outside of the required timeframe to licensing.

Correction Narrative: The operation provided a document of a written corrective action for the staff member. The corrective action clarified the standards for reporting to law enforcement and licensing.


raw_content: During the inspection, two staff records were requested, however licensing was unable to thoroughly evaluate these records as the personnel files were not immediately available.

Standard Number / Description: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

Correction Narrative: The Shelter Director met with the Human Resources Director to go over the requirements in relation to this standard. In the future, employee files will be moved to an all-electronic format, but in the interim, it was determined that employee information gathered by HR would be forwarded to the Shelter Director so delays when inquiring staff files would no longer occur. The Senior Division Director and Senior Grants and Contracts Specialist will also have access should the Shelter Director be out of the office.


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

raw_content: During the inspection, children's medication records count were observed to not match the number of actual tablets/pills left.

Correction Narrative: The Shelter Director held a team meeting to discuss the feedback received from licensing. It was determined that their medication sheets would include a medication count after the following distribution times: AM, NOON, PM, and BEDTIME. They will continue to do medication counts on the overnight as well. It was reported this change will allow them to accurately demonstrate the daily count of each prescribed medication within two-hours of dispensing said medication to the child and ensure that they're in compliance. The operation attached the updated medication sheet as well.


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

raw_content: During the inspection, there were staff who were inactivated past the 7 day required timeframe of being terminated/resigned. There were 9 out of 13 staff that were inactivated past this timeframe and there were 2 staff that were reported to be terminated who had not been inactivated.

Correction Narrative: The operation Director met with the Human Resources Director to go over the requirements in relation to this standard. HR continues to oversee the background check process for all operation staff and is responsible for inactivating background checks. They were made aware of the need to inactivate background checks within 7 days of leaving the operation. Given their recent turnover, the HR Director confirmed that they would personally take this on and would set up weekly reminders to ensure that the operation is in compliance with the Minimum Standards. The HR Director also confirmed that they would be sure to emphasize how critical this is with their next HR Generalist and will also spot check periodically. The Shelter Director will also confirm deactivation with HR prior to the 7th day.


facility_name: Brownstone Residential Care

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

raw_content: One of three employee files reviewed did not contain verification the employee had a refresher EBI training in about 9 months.

Correction Narrative: A phone call was held with the operation's owner which indicated all youth have been discharged from the operation. On Oct. 7, 2024, the owner confirmed that the operation will be ceasing operations on a voluntary suspension basis until a new location can be found.


summary: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

raw_content: One out of three youth files reviewed did not contain a debriefing following a youth's return from unauthorized absences.


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

raw_content: During the walkthrough at the operation, it was observed the medication lock box was not double locked and access was available to youth in care.


summary: 748.3931(a)(1) - Weapons- Handguns are not permitted at an operation or during any type of activity.

raw_content: During the course of the investigation, it was discerned staff transported a child in a vehicle with a handgun present as well as another staff reportedly storing a handgun in their vehicle on site.


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: A caregiver was photographed smoking while transporting youth in care in a vehicle.

Correction Narrative: Corrected.


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: During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas.  The facility is no longer in operation, mitigating risk in this standard.


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

raw_content: During the investigation, it was discerned the owner of the operation questioned children following investigation issues, promised them bribes to present well, instructed staff to alter or omit documentation to prevent or reduce investigations, and failed to respond appropriately to allegations by staff and children.  The facility is no longer in operation, mitigating risk in this standard.


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

raw_content: During the inspection, it was discovered staff and children expressed concern that an employee transported children and served as a caregiver while under the influence of alcohol and administration failed to respond in a timely and appropriate manner.  The facility is no longer in operation, mitigating risk in this standard.


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

raw_content: During the investigation, it was discovered a child with sexual aggression history was placed with a roommate who had sexual victimization history, violating the aggressor child's service plan.  The facility is no longer in operation, mitigating risk in this standard.


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

raw_content: The operation was not in ratio during awake hours.

Correction Narrative: A phone call was held with the operation's owner who stated no youth are currently placed at the operation. Voluntary closure or suspension of the operation is pending.


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

raw_content: One out of two employee files reviewed did not contain documentation to show employment history was verified.

Standard Risk Level: Medium Low

Correction Narrative: An email was received from the operation which included an employment history check form for verification for the employee who did not have one previously.


raw_content: The administration/owner did not use prudent judgment when requiring the child to get back to the operation and not offering to get the child a ride back to the operation when the child made him aware that he could not get a ride.

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


raw_content: Children in care were assisting staff and intervening with another child in care having a manic episode.


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

raw_content: During the inspection, the operation was observed to not be clean evidenced by a urine smell in two of the bedrooms and old food on the floor behind the stove.


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

raw_content: Three out of three employee files reviewed did not contain reference checks.

Correction Narrative: An email was received from the operation's owner that included a corrective action plan indicating a reference check template was created to be utilized in the future to ensure reference checks are documented. A copy of the template was also included in the email.


summary: 748.3273(2) - First Aid Kits-Each one must contain adhesive tape

raw_content: Four out of four first aid kits observed during the inspection was missing adhesive tape, thermometers, tweezers, and disposable gloves.

Category: Safety and Emergency Practices


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: One of three youth files reviewed did not include an immunization record or reasoning explaining for the lack of it.

Category: Child Care

Correction Narrative: An email was received from the operation's owner that included a corrective action plan indicating the youth's file has been updated. The electronic file was reviewed in ExtendedReach and verified to have been updated.


summary: 748.1501(a)(4) - Dental care-Children in care must receive dental care as needed for ongoing maintenance of dental health

raw_content: One out of three youth files reviewed had a dental appointment dated longer than the required maintenance of 6 months.

Correction Narrative: An email was received from the operation's owner that included a corrective action plan indicating the dental visit verification has been added to the youth's file. The electronic file was reviewed in ExtendedReach and verified to have been updated.


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

raw_content: The serious incident reports reviewed did not detail interventions made following the incidents.

Correction Narrative: During exit interview of inspection, the operation's owner stated the staff that wrote the two incident reports was terminated due to reasons such as not adhering to directives like accurately writing incident reports. He also stated he has conducted conferences with staff about documenting accurately and effectively for future occurrences.


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: A cleaning product was observed during the inspection accessible to youth in care under an unlocked bathroom sink.


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

raw_content: Two medications reviewed for one youth in care was documented with the wrong ending count.

Correction Narrative: Corrected


summary: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator

raw_content: The operation has been without an administrator for more than 120 days.

Correction Narrative: During a monitoring inspection #3982603, the operation's owner indicated he has hired an administrator and their background check has come back as eligible. This was verified in CLASS.


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

raw_content: Operation staff laid on top of a child in care to gain control during a restraint.


raw_content: The operation has not had an administrator for more than 90 days.

Standard Number / Description: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator


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

raw_content: Two out of three employee files reviewed only contained verification for 8 hours completed for EBI training instead of the required 16 hours.

Correction Narrative: An email was received from the operation's owner, Brandel Brown, which included the training certificates for the other half of the pre-service EBI training taken by the two employees who were missing it in their files originally.


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: Service Plan completed for a child in care on 08/12/2023 indicates that the child should not be placed in a bedroom with any other children. This child was instead placed in a room with two roommates.

Correction Narrative: An email was received from the operation's owner which included a corrective action plan that indicates the operation corrected the original service plan and has implemented it.


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

raw_content: Operation provided an inaccurate copy of a child's service plan.

Correction Narrative: An email was received from the operation's owner which included a corrective action plan that indicates the operation's Treatment Director and Administrator will be responsible for auditing every service plan for accuracy before it is finalized.


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

raw_content: Records requested from the operation on 11/21/2023 were not received until 12/20/2023.

Correction Narrative: An email was received from the operation's owner which included a corrective action plan that indicates the operation recently hired an Administrator whose duty will be to provide requested documentation.


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: During walk through, it was observed that the childrens bathroom was unequipt with handsoap and tissue.


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

raw_content: During walk through, it was observed that substance controll medication was not double lock.


raw_content: The operation has not had an administrator for more than 60 days.


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

Correction Narrative: The staff list provided still included 4 previous employees. this was corrected.


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

Correction Narrative: An attempt was made by CCI to do an on-site inspection and no one was there. this was corrected


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: It was observed that there were two originally packaged packs of fish in the sink in water thawing. The staff removed the packages of fish and begin to prepare dinner.


Correction Narrative: Records were  requested at the start of the inspection licensing did not have access by the conclusion of the inspection. this was corrected.


raw_content: CCI Investigator requested for medication logs for all children for 2023 but the operation was not able to provide the records upon request.

Correction Narrative:
The operation stated in its written correction provided via email on 4-15-24 that they are currently using an electronic portal system (Extended Reach) that accurately stores and saves the records.

A follow up inspection (#3999432) was completed on 4-29-24 in which medications and their corresponding medication logs were reviewed for compliance and found to be compliant.


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

raw_content: 2 same medications log for the month of September 2023 for 1 child med log was reviewed. One of the med logs stated that Fluticasone Propio 50 MG was administered for the 1st of September 2023 at 7:15am and initialed by one staff while the second medication log for the month of September 2023 for same child stated that same medication was administered on the 1st of September at 7am and initialed by another staff.


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.

Correction Narrative:
The unauthorized absence incident is documented to have occurred on 9/12/23 at 3:45pm, but the children's parent was not notified until 9/13/23 at 8:37pm.
This has been corrected.


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

raw_content: One out of three employee files reviewed did not include a signed and notarized Affidavit for Employment.

Correction Narrative: A corrective action plan was received via email from the operation indicating the missing document had been uploaded to their external database. This was verified. The corrective action plan also indicated the operation will not move forward in the hiring process with a candidate if all required documents are not received timely.


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: Three out of three youth files reviewed were missing several documents in the files that the operation provided separately.

Standard Risk Level: Low

Correction Narrative: An email was received from the operation that included a corrective action plan that indicated the missing documents had been uploaded to their external database. This was verified. The corrective action plan also indicated the operation will ensure documents are uploaded to the database within 48 hours after appointments or 7 days after a placement. This will be ensured by the compliance team.


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

raw_content: A staff member admitted to calling a child in care a "crackhead".

Correction Narrative: A corrective action plan was submitted via email on August 28, 2023 that indicated the employee involved was taken off the schedule and had to undergo retraining of the Minimum Standards. It also indicated the employee had a conference to be reminded of children's rights and effective communication with the children in care. The corrective action plan indicates new hires will also get the same extensive training to ensure this doesn't occur again, and it will be ensured by the owner. On August 29, 2023, a couple of youth were interviewed at their school and denied any inappropriate discipline still occurring at the operation. The interviews are in Chronology.


summary: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: One out of two employee files reviewed did not contain a signed affidavit for employment, indication of date of hire, or verification of completed TB skin test.

Correction Narrative: A phone call was received from the operation's owner stating the employee had provided false documentation for the missing items originally; therefore, disciplinary action will occur for the employee and true documentation will be attained and provided.


raw_content: The operation's Treatment Director's personnel file was not provided as requested.

Correction Narrative: A phone call was received from the operation's owner indicating that the Treatment Director no longer is employed by the operation and he will be removed from their employee list in the provider portal.


summary: 748.3239(a)(3) - Evacuation-During each fire drill, children must be able to safely exit building to designated meeting place within 3 minutes

raw_content: Twelve fire drills conducted by the operation were indicated to have lasted significantly longer than three minutes.

Correction Narrative: An email was received from the operation's owner that included a copy of the evacuation drills conducted thus far this year. The new drills met the time requirement.


summary: 748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care

raw_content: Two out of two first aid kits did not contain a guide, tweezers, gloves, scissors, tape, or gauze pads. One out of two first aid kits did not contain a thermometer.

Correction Narrative: Corrected.


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: Cleaning supplies were observed to be stored in two accessible areas for youth in care.


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

raw_content: One out of two employee records reviewed indicated the TB skin test was completed more than 30 days after hire.

Correction Narrative: A corrective action plan was received via email from the operation's owner indicating the administrator will be responsible for ensuring TB skin tests are scheduled for employees during their orientation week to ensure they are completed timely.


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

raw_content: Two out of two serious incident reports reviewed did not include the interventions made by staff or the resolution to the incident.

Correction Narrative: An email was received from the operation's owner which included the updated incident reports to include the missing information.


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

raw_content: Staff members were observed not being in the proper caregiver/child ratio. Two staff were interviewed and confirmed they were out of ratio for a short period of time.


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

raw_content: Not all requested child documents were provided or provided within the specified timeframe.

Correction Narrative: An email was received from the operation's owner, Brandel Brown, including a corrective action plan that indicated all requested documents will be provided by the operation's case manager within 24 hours moving forward. Completion of this will be ensured by the administrator per the CAP.


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: Two discharged youth's medications were stored in the same box with current youth's medications.


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: A medication label was said to have had the wrong quantity printed compared to the medication log reviewed, but the operation failed to get the label corrected.

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the administrator will be responsible for contacting the pharmacy within 24 hours after discovering a medication label error.


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

raw_content: There is not always administrative staff present at the operation during normal business hours to assist with administrative duties such as allowing Licensing to conduct an inspection.

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the administrator will be responsible for hiring a case manager to be present at the operation during normal business hours.


raw_content: All active records were not in the files reviewed timely.

Standard Number / Description: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the administrator will be responsible for ensuring all documentation is compiled within 14 days of placement. The plan also indicated the caseworker will be contacted about missing documentation within three days after placement to ensure the documentation is received timely.


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

raw_content: The unauthorized absence log was not available upon request.

Correction Narrative: A phone conversation was held with the operation's owner, Brandel Brown. Mr. Brown requested for an extension to provide the AWOL log since an employee initially stated they accidently took it home but recanted recently. He stated he would have to create a new log by reviewing through all of the past incident reports. A week extension has been granted (January 17, 2023). On January 17, 2023, an email was received from the operation's owner, Brandel Brown, which included the Unauthorized Absence Log for the operation from the entire year of 2022.


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

raw_content: The serious incident report did not have the names of the children involved in the incident.

Correction Narrative:
A phone call was received on Monday, Feb 13, 2023 from the operation's owner, Brandel Brown, to the licensing representative, Jassica Brunson, to inquire about corrections needed for citations that were issued. Mr. Brown stated he was made aware of the corrections needed today but not about the citations being issued. The licensing rep was not made aware of citations being issued as well; therefore, an extension will be granted until Wednesday, Feb 15, 2023.

2/15/23 The remedy for this deficiency contine documentation of serious incident reports update / electronic incident report which includes all requirements. Staff has been notified and will no longer document any serious incident reports on the document without all required information and will be checked by Director Sabrina Sinclair.


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

raw_content: During the inspection, observed a window to be broken in a bedroom.  Window was taped with Plexiglas glass for temporary repairs.  Observed a part of a bedroom door frame to have been detached from the wall.

Correction Narrative: Window has been replaced and closet door frame repaired as well. Corrected


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

Deficiency Narrative: The unauthorized absence log was not available upon request.


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: During my inspection, it was observed in each bathroom to not have personal towels to dry hands.  In one bathroom, there was no handwashing soap.

Correction Narrative: Hand washing soap, papertowels, and tissue were observed in both bathrooms. Corrected


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

raw_content: Three out of four child records reviewed did not contain the known allergies on the exterior of the child's file.

Correction Narrative: During inspection #3920179, face sheets were observed being printed and placed on the exterior of the child's files that were missing one to show any known allergies and/or chronic conditions.


summary: 748.3273(2) - First Aid Kits-Each one must contain adhesive tape

raw_content: Two out of two first aid kits were observed to be missing scissors, gloves, cotton balls, adhesive tape, tweezers, thermometers, adhesive bandages, and the first aid guide.


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

raw_content: Two window blinds were observed to be damaged.

Correction Narrative: Corrected


summary: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: Two out of three employee files reviewed did not contain a signed affidavit for employment.


summary: 748.363(1) - Personnel records-Include date of employment

raw_content: Two out of three employee files reviewed did not have an identifiable date of employment for the employee.


summary: 748.393(a) - Active child record-kept at operation where child is receiving services

raw_content: Some active child records were not available to be reviewed due to not being at the operation at the time of inspection.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: One out of three youth records reviewed did not contain an immunization record or documentation to verify attempts to obtain were made.


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

raw_content: Two out of three medication records reviewed did not list all medications, strength, dosage, and frequencies prescribed.


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

raw_content: A youth did not obtain follow up treatment in the recommended timeframe as recommended by a healthcare professional.


raw_content: One out of one employee file reviewed did not contain a signed Employee Affidavit.

Standard Number / Description: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, stating the employee will be terminated due to their lack of cooperation in getting onboarding tasks completed timely.


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

raw_content: One out of three youth files reviewed did not contain the PLSP's signature on the admission assessment.

Correction Narrative: An email was received from the operation's owner that included a copy of the signed admission assessment.


summary: 748.1205(b)(2) - Admission Documentation-For child admitted for emergency care svcs, meet 748.1205(a) within 72 hrs or document efforts made to obtain information

raw_content: One out of three youth files reviewed did not contain documentation to indicate immunization records were attempted to be obtained.

Correction Narrative: An email was received from the operation's owner that included a copy of the youth's immunization record.


summary: 748.1209(c)(1) - Child Orientation - Include information on how to make complaints to outside agencies

raw_content: Two out of three youth orientation did not include process for making complaints to outside agencies.

Correction Narrative: An email was received from the operation's owner that included a copy of the updated youth orientation handbook.


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

raw_content: Two staff members with pending background checks were supervising children in care.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, stating the employees with pending background checks were only allowed to complete trainings and not supervise the youth in care once informed of the citation. He confirmed one of the employee's background check has returned as eligible and the other employee will be terminated due to their lack of cooperation in getting their fingerprinting done timely.


raw_content: One current employee did not have an active background check.

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

Correction Narrative: During the exit interview of the inspection, Mr. Brandel Brown, the operation's owner, stated he does not plan to keep Ms. Kenya Halley as an employee due to her age and not being eligible to be a caregiver. Therefore, he has no desire to rerun her background check.


summary: 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units

raw_content: Smoke detector was observed to have a beeping sound indicating that battery was low or needs to be replaced.

Correction Narrative: Deficiency corrected by batteries being changed in all smoke detectors.


raw_content: One of three child records read did not have a signature of professional level service provider not a date.

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

Correction Narrative: Deficiency was corrected by signature being added to document.


raw_content:
A hole was observed in the wall of the dining room of facility.
A broken cabinet door was observed in the wet bar area.
Door of 2nd restroom was observed to be cracked.
Carpet in storage room was observed to be soaking wet.
Outlet covering in the living area was observed to be exposed.
Cracks were observed in a couple of the walls along with the floor in the dining area appearing to be slanting.

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

Correction Narrative: Deficiency corrected by operation being cleaned and repaired.


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

raw_content: Staff records were not available to be reviewed immediately at operation.


summary: 748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner

raw_content:
Fence on backyard was exposed with barbb wire and other  boards were observed to be warped.
Some boards in the backyard fence were missing.
There broken chairs both in the front and back yards.
Standing water was observed on the trash can lid in the backyard of facility.
Standing water was observed in two buckets in the backyard yard.
Grass in both front and back yards was failed to be maintained.


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

raw_content: One of three staff records read was observed to be missing date of pre-service training.

Correction Narrative: Deficiency corrected by date being added to training certificates.


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

raw_content: Multiple broken furniture were observed in the front yard of the operation.


raw_content: Three doors off the hinges were observed leaning against a wall in a storage room easily accessible to youth in care inside a youth bedroom.

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


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

raw_content: Two out of three child files reviewed did not have in a clearly visible place to indicate if the child had any known allergies or chronic conditions.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, on February 16, 2022 requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. An email was received from the operation on February 23, 2022 including a copy of the updated face sheets for the youth which indicated any allergies or known conditions.


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

raw_content: One out of three child files reviewed did not contain a discharge summary with all required components per the minimum standards.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, on February 16, 2022 requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. An email was received from the operation on February 23, 2022 including a copy of the discharge summary.


summary: 748.531(a)(3) - Child-care administrator-Is full-time employee of the operation

raw_content: The operation's administrator does not work full time hours at the operation.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, on February 16, 2022 requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. An email was received from the operation on February 23, 2022 including a copy of the staff schedule to verify the administrator's scheduled work hours.


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

raw_content: Three out of three child medication logs reviewed did not document the exact time administered.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, on February 16, 2022 requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. An email was received from the operation on February 23, 2022 including a copy of a medication log that included the time of administration.


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

raw_content: Two out of three child files reviewed did not contain a preliminary service plan.

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, on February 16, 2022 requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. An email was received from the operation on February 23, 2022 including a copy of the missing preliminary service plans for both youth.


raw_content: Three out of three medication records reviewed did not contain the dosage documented on the medication record.

Standard Number / Description: 748.2151(c)(4) - Medication record - must include medication name, strength and dosage

Correction Narrative: A phone call was received from the operation's owner, Brandel Brown, requesting an extension to correct the citation. An extension has been granted until Monday, February 21, 2022. On March 3, 2022, an email was received from the operation which included updated medication logs to include all required components.


raw_content: During the walk-through an operation of holes were observed in the children in care bedroom walls,  30 gallon trash can filled with water in the backyard, missing boards on the fence outdoors, and mold in a closet in children bedroom,

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


raw_content: During the walkthrough, two wood plank boards were observed lying on the floor exposed in one of the common areas.


raw_content: Two out of two youth files reviewed did not have the youth's known allergies or medical conditions documented in a clearly visible place within the file.

Standard Number / Description: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

Correction Narrative: An email was received from the operation that included a copy of the two clients' face sheets which indicated allergies or medical conditions.


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

raw_content: Two out of two youth files reviewed did not have a second means of identification for the youth in care such as a client number.

Correction Narrative: An email was received from the operation that included a copy of the two clients' face sheets which indicated a second form of identification.


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

raw_content: One out of one serious incident report reviewed was not fully completed to contain all required information.

Correction Narrative: An email was received from the operation that included a copy of the updated incident report reviewed. All blanks were filled in to include all required components.


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: One out of three staff files reviewed did not contain documentation of a TB skin test being completed.

Correction Narrative: An email was received from the operation's director indicating the staff without the TB skin test in their file is no longer employed by the operation as of 12/25/21.


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

raw_content: Two out of three employee files reviewed did not contain verification of the required pre-service training regarding normalcy.

Correction Narrative: An email was received from the operation including a copy of the document for verification that it was completed.


summary: 748.881(4) - General pre-service training curriculum-Includes steps to preventing the spread of communicable diseases

raw_content: Three employee files reviewed did not contain verification of the required pre-service training regarding communicable diseases.


summary: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

raw_content: One out of three employee records reviewed did not contain documentation of a current TB test to meet the requirements.

Category: Personnel


summary: 748.881(5) - General pre-service training curriculum-Includes location and use of fire extinguishers and first aid equipment

raw_content: Three employee files reviewed did not contain verification of the required pre-service training regarding location and proper use of the fire extinguisher and first aid equipment.


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: Two out of three employee records reviewed did not contain an acknowledgement signed of reporting abuse/neglect.


summary: 748.881(3) - General pre-service training curriculum-Includes procedures to follow in emergencies

raw_content: Three employee files reviewed did not contain verification of the required pre-service training regarding emergency procedures.


summary: 748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record

raw_content: Three employee records reviewed did not contain verification of orientation completed.


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

raw_content: One out of three employee files reviewed did not contain an Affidavit for Employment.


summary: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: Two out of three employee records reviewed did not contain an acknowledgement signed of the operational policies.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: Two out of three employee records reviewed did not contain verification of the employee's educational qualifications.


summary: 748.881(1) - General pre-service training curriculum-Includes topics appropriate to the needs of children for whom the caregiver will be providing care

raw_content: Three staff files reviewed did not contain verification of pre-service training regarding the needs of children.


summary: 745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access

raw_content: Three employee records reviewed did not contain verification of pre-employment drug tests completed.

Correction Narrative: Verification of employee drug tests were sent via picture mail from the operation's owner.


summary: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

raw_content: There is no verification of licensure for the treatment director in the file.


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

raw_content: Missing from policy.

Deficiency Narrative: Missing from policy.


summary: 748.161(b) - Fiscal requirements - Maintain complete financial records that comply with Generally Accepted Accounting Principles

raw_content: Missing policy.

Category: Organization and Administration

Deficiency Narrative: Missing policy.


summary: 748.161(a)(1) - Fiscal requirements - pay employees timely

raw_content: No policy about fiscal requirements.

Deficiency Narrative: No policy about fiscal requirements.


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

raw_content: Policy does not indicate the area designated inside of the house to take shelter.


raw_content: In staff file missing a place for how they meet the age requirement.

Standard Number / Description: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position


summary: 748.363(3) - Personnel records-Include current job description

raw_content: In staff file missing a place for the job description.


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

raw_content: Loose wooden boards and a broken pipe were observed lying around in the backyard.


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

raw_content: The shed in the backyard is not in good repair or structurally sound.


raw_content: In staff file missing a place for a statement that staff has read the operations policies.

Standard Number / Description: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies


summary: 748.117 - Transitional living policy - For operations who offer a transitional living program, you must develop policies

raw_content: Missing entire policy

Deficiency Narrative: Missing entire policy


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


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: In staff file missing a place for TB test.


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

raw_content: No thermometer in refrigerator.

Deficiency Narrative: No thermometer in refrigerator.


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

raw_content: In admission assessment missing a spot for the phone number and address of the conservator.


summary: 748.1205(a)(6) - Admission Documentation-Includes medication the child is taking

raw_content: Missing a place for medications child is taking.


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

raw_content: Missing a log for unauthorized absences.


summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content: There is no abuse neglect policy.

Deficiency Narrative: There is no abuse neglect policy.


raw_content: In staff file missing a place for certifications such as high school diploma.

Standard Number / Description: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position


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

raw_content: Missing from policy.


summary: 748.1209(c)(1) - Child Orientation - Include information on how to make complaints to outside agencies

raw_content: Missing how to make outside complaints.

Deficiency Narrative: Missing how to make outside complaints.


summary: 748.1209(b)(12) - Child Orientation-Include general daily schedule for routine activities

raw_content: Missing a general daily schedule for children.


summary: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

raw_content: No thermometer in freezers.

Deficiency Narrative: No thermometer in freezers.


summary: 748.363(12) - Personnel records - Include any documentation of the person's performance with the operation

raw_content: In staff file missing a place for staff evaluations.


summary: 748.3239(c) - Evacuation-Emergency evacuation & relocation plans must be routinely practiced at different times during hours of operation


facility_name: The Ambience Residential Treatment Center

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

raw_content: During the investigation inspection, the window screen on the outside front entry, was observed torn and damaged.

Correction Narrative: Window screen on the outside front entry has been replaced [01/14/25] Window screen inspections will be included in the daily check list and the Admin staff will also conduct a walk through to address every maintenance.


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: During the investigation inspection, a one-gallon bottle of drain clog dissolver was observed unlocked and accessible to children.


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.

Deficiency Narrative: During the investigation inspection, a one-gallon bottle of drain clog dissolver was observed unlocked and accessible to children.


raw_content: During the investigation inspection, the window screen on the outside front entry, was observed torn and damaged

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


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 restrained with a seat belt when secured in a vehicle.

Correction Narrative: The operation implemented the following transportation and supervision protocol: All staff are required to follow established transportation safety procedures during every resident transport. This includes ensuring proper supervision, adherence to seating arrangements, and always maintaining safety. All staff have been re-informed of transportation and supervision requirements. Verification of this re-training has been documented in each employees record to confirm compliance. A current staffing schedule must be maintained to demonstrate that supervision ratios are being met for all youth, including CSC supervision requirements. The schedule must clearly identify which staff are assigned to each youth requiring 1:1 supervision. All vehicles used for transportation must have child safety locks always engaged. Staff must complete and document a vehicle safety inspection checklist before each transport to ensure the vehicle is safe and compliant.


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

raw_content: The operation did not adhere to their policy requiring vehicles doors to remain locked at all times.

Correction Narrative: The operation implemented the following transportation protocol: All staff are required to follow established transportation safety procedures during every resident transport. This includes ensuring proper supervision, adherence to seating arrangements, and always maintaining safety. All staff have been re-informed of transportation and supervision requirements. Verification of this re-training has been documented in each employees record to confirm compliance. A current staffing schedule must be maintained to demonstrate that supervision ratios are being met for all youth, including CSC supervision requirements. The schedule must clearly identify which staff are assigned to each youth requiring 1:1 supervision. All vehicles used for transportation must have child safety locks always engaged. Staff must complete and document a vehicle safety inspection checklist before each transport to ensure the vehicle is safe and compliant.


summary: 748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing

raw_content: A child in care was found to be in need of footwear. The shoes the child was wearing were old and worn down with holes.

Correction Narrative: On 9-22-25 an email was received from the Administrator. The email has a photo attached of shoes said to belong to the child named in the investigation. There are four pair of shoes that appear to be new and in good condition. End.


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

raw_content: Repairs are needed for the window bllinds, cracked doors, stained walls, chipped paint on walls, chipped surface on picnic tables, stained bathroom tub, chipped paint on bahtroom sink.

Correction Narrative: During and in-person follow up inspection a walkthrough of the operation was conducted observing physical site. The concerns noted in this investigation have been corrected. There were no additional conerns noted during the walkthrough.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: The opertoion has not been administrating any suicide screening when children are being admitted into their placement.

Correction Narrative: On 6/5/2025, the operation conducted suicide screening on all children admitted into their operation. The operation understands that they must complete suicide assessment at least every 30 days as they are and RTC.


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: During the walkthrough the chemical closet was unlocked.


summary: 748.63(1) - Types of services-Operation must only provide services listed on permit

raw_content: The operations permit does not have IDD or Autism as services the operation can treat.

Correction Narrative: The operation sent a CAP stating they were going to update their policies and procedures and have their permit reflect their new services. Document uploaded. Admin staff also confirmed that the process has begun.


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

raw_content: The 4 SIRs reviewed had limited details regarding the incidents.

Correction Narrative:
The operation submitted the following correction: the operation will revise handover documentation i.e (Progress Notes) to ensure adequate handover of information about residents from Caregiver to Caregiver.
The operation will ensure in-house training of Incident reporting documentation, in providing, the trigger contributing factor that led to the Incident, every intervention made during the incident and restoring residents to normal activities.


summary: 748.3237(c) - Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector

raw_content: Front and Back exit doors can only be opened with the use of a staff's fingerprint. There is no written approval for these doorknobs on file from a fire inspector. The operation reports a fire inspector is scheduled to come out on 2/17/2025 to assess the doorknobs for approval.

Correction Narrative: An inspection was conducted on 6/5/2025 the operation has a locked device which is connected to the fire alarm sprinkle system thatwill allowed the doors to open in case of an emergency. The thumb print lock was removed.


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

raw_content: During the course of this investigation, the operation was unable to provide a suicide screening conducted for a child that was exhibiting warning signs.

Correction Narrative: The operation will ensure that a suicide screening is done with a child shows or exhibits suicidal ideations.


summary: 748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.

raw_content: During the course of the investigation, the operation was unable to provide the weekly screenings after the child returned to the operation.

Correction Narrative: Operation will ensure a weekly screening is done weekly with the child for the first 30 days, and it will be separately from their weekly Therapy.


summary: 748.125(f)(2)(B) - Post hospitalization protocols must include creating or reviewing and updating the childs safety plan.

raw_content: During this investigation, it was found that the safety plan was not updated as needed after returning from the psych hospital.

Correction Narrative: The operation will update the service plan, and it will be tailored to the child's triggers and what coping skills for the child to learn.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content: During this investigation, the operation was unable to provide documentation showing that the child met with the PLSP within 24 hours of returning to the operation.

Correction Narrative: The PLSP will conduct a Post hospitalization interaction with every child who has been hospitalized for certain behaviors to know the level of triggers to help mitigate further risk.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: The child's file was missing the required discharge documentation.

Correction Narrative: An email was sent with the following corrective action item: Moving forward all kids discharged from the Facility would have a discharge summary signed by all responsible parties and Treatment Team


summary: 748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling

raw_content: One employee fille reviewed during inspection was missing the education requirements

Correction Narrative: The staff provided a current copy of the education record.


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

raw_content: Staff filed review last EBI training was on 12/02/2023

Correction Narrative: All operation staff completed an EBI refresher training on 08/21/24


summary: 748.561(2) - Responsibilities of Professional level service provider-Developing, reviewing, and updating of service plans for a child in care

raw_content: The service plan completed on 6/24/2024 was reviewed and the service plan was not signed by the child, and he is able to write. The service plan does not address plans to implement the recommendations given for medical and mental health follow up recommendations by service providers. Signatures were also missing and not dated by Caseworker for child noting that they received and reviewed the recommended service plan for child.

Correction Narrative:
An email was sent with the following correctives: 1. The PLSP (Professional Level Service Provider) responsible for this document has noted the importance of filling out the service plan document with timely information.
This will also be reviewed by the case manager and the LCCA for compliance before they are issued and filed


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

raw_content: Child records for medical reviews and documents were not current. Updated forms 2403 will need to be completed and filled out at every appointment and med appointment.

Correction Narrative:
An email was sent with the following correctives: 1. The Case Manager will ensure that all kids who go for medical visits have their form 2403
forms filed by the provider and Direct care staff taking them for this visit.
2. A separate sheet which is attached to the Form 2403 has been created of each child that state their current medication and dosage.
3. Moving forward The Ambience will fill out Forms 2403 for each child electronically before each visit, updating all current medications.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content:
The Preventing and Recognizing Youth Sexual Abuse training was taken on 2/2/2023, and again on 6/10/2024, 129 days late.

The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/11/2023, and again on 6/11/2024, 153 days late.

The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/24/24 after the staff was counted in ratio on 12/25/23.

The Preventing and Recognizing Youth Sexual Abuse training was taken on 5/21/2024 after the staff was counted in ratio on 5/11/2024.

The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/2/2024 after the staff was counted in ratio on 12/20/2023.

The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/2/2024 after the staff was counted in ratio on 12/24/2023.

Correction Narrative: An email was sent with the following correctives:1. A spreadsheet tracker has been implemented to track due dates for training. This will be used to remind staff before training expires. For new staff, they will not in ratio until training is completed. LCCA will review this tracker before the schedule is made.


summary: 748.885(1) - General pre-service training curriculum- Must include identification of psychotropic medications.

raw_content: The DFPS Psychotropic Medication training was taken on 1/2/2024 after the staff was counted in ratio on 12/24/2023.

Correction Narrative:
An email was sent with the following correctives1. For new staff, they will not in ratio
until training is completed. LCCA will review this tracker before the schedule is made.


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

raw_content:
The DFPS Trauma Informed Care Training was taken on 1/11/2023 and again on 6/11/2024, 152 days late.

The DFPS Trauma Informed Care Training was taken on 5/18/2023 and again on 6/10/2024, 25 days late.

Correction Narrative:
A spreadsheet tracker has been implemented to track due dates for trainings. This will be used to remind staff before training expire.
For new staff, they will not in ratio until training is completed. LCCA will review this tracker before the schedule is made.
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