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

raw_content: Caregivers are not following child's service plans. A child in care has not been provided with the level of supervision, according to the child's service plan.

Correction Narrative: Staff were interviewed and they indicated that they were retrained and updated on service plan.  The service plans are available at anytime for the staff to review if they have any questions.


state: TX

facility_name: Haven of Rest Care Home

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

raw_content: Children who had a history of being runaways were allowed to go on unsupervised walks.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: Staff and children interviewed indicated that they are not allowed to go unsupervised without a staff unless permission from their caseworker.  This will faciliticate through a meeting.


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: Two children were discovered absent from the operation for more than six hours and the caregivers called this incident into the statewide hotline the following day.

Standard Risk Level: Medium

Correction Narrative: An email was received from the Administrator indicating that indicated both the Management and Staff of Haven of Rest were retrained on the policy on unauthorized absences and the timeframe that is required. An inspection is scheduled for 4/18/25. Staff were interviewed and indicated they were instructed about the agency and minimum standard policies..


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

raw_content: One staff members did not demonstrate appropriate care when yelling at children.

Standard Risk Level: Medium High

Correction Narrative:
An email was received from the Administrator on 04/10/25 indicating the staff has spoken to each caretaker regarding this policy and the standards that are required for discipline. An inspection is scheduled for 4/18/25.

An inspection was conducted on 04/18/25, staff and children were interviewed regarding discipline.  The staff indicated that they were retrained on discipline and especially tone of voice.  The children denied any inappropriate discipline.  They were also trained on triggered.


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: Children in care were found to be in possession of e-cigarettes and other illegal substances.

Correction Narrative:
An email was received from the Administrator indicating that they retrained staff on the search policy of the operation. They will conduct daily searches on residents entering the home from school or other outings to ensure that no tobacco, e-cigarettes, vaporizers or other paraphernalia is present. All backpacks, pockets, shoes/socks will be checked to ensure these items are not hidden.   Additionally, random checks of bedrooms and bathrooms will be checked for the same.  All caregivers have been advised of the search policy and will work toward making the operation a safe environment, free of tobacco and related products for all residents. An inspection is scheduled for 4/18/25.

An unannounced inspection was conducted on 04/18/25. Staff and children interviewed indicated that they are not allowed to go unsupervised without a staff unless permission from their caseworker.  This will facilitate through a meeting.


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

raw_content: The administrator was observed preparing medication for the children more than an hour before the medication was administered.

Correction Narrative: The medications were observed and there was not any medication pre-prepared.  The logs were curent.  Staff were interviewed and they confirmed that there is a new procedures and they are trained in administering and documenting the logs.  Interviews with the children to confirm who administered the medication was also conducted as verification. Copies of the sign in sheets of the training was received.


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

raw_content: The medication log was reviewed during the inspection on 1/16/25. The medication log was last updated on 1/12/25.

Correction Narrative: Medication logs were reviewed and it indicated which staff administered the medication and the time. The logs were curent.  Staff were interviewed and they confirmed that there is a new procedures and they are trained in administering and documenting the logs.  Interviews with the children to confirm who administered the medication was also conducted as verification. Copies of the sign in sheets of the training was received.


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

raw_content: The medication logs only contain the signature and name of the administrator who does not administer the medication.

Correction Narrative: Medication logs were reviewed and it indicated which staff administered the medication. Staff were interviewed and they confirmed that there is a new procedures and they are trained in administering and documenting the logs.  Copies of the sign in sheets of the training was received.


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

raw_content: A staff put a child in a restraint when they tried to run away.

Correction Narrative: Staff were spoken to and the children in care regarding EBI. The staff confirmed that they were re-trained by the Administrator regarding appropriate restraints.  None of the children indicated that they had been restrained.


summary: 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

raw_content: Staff were witnessed sleeping when they were supposed to be supervising the children.

Correction Narrative: Staff and children were interviewed and they indicated they have not seen any caregivers sleeping lately. Staff stated that they were re-trained on supervision and why they are not allowed to sleep on their shift at anytime.


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

raw_content: A staff member did not follow the agencies policy regarding restraints.

Correction Narrative: Staff were interviewed and they indicated that the Administrator re-trained and spoken to them individually about the operations policy. They also stated the policies are available for review at any time.


summary: 748.915(b)(4) - Pediatric CPR training documentation must include the trainer's name and qualifications.

raw_content: The two CPR and first aid training that were reviewed did not have the trainers qualifications. It also did not have the length of hours 748.915(b)(6).

Category: Training and Professional Development

Standard Risk Level: Medium Low

Correction Narrative: The Executive Director indicated that have a person reviewing each file to ensure accuracy. Copies of the certificates were received showing that the training has been completed.


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

raw_content: A caregiver did not complete the EBI training within 6 months of the previous training date.


summary: 748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours

raw_content: There were multiple certificates that did not have the length of the training.


summary: 748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint

raw_content: Two children's file that were reviewed did not have the information documented regarding the contraindications restraints.

Category: Admission, Service Planning, Discharge

Correction Narrative: The Executive Director indicated that they would train the staff on making sure all areas are filled out on the admission assessment. They also have a person reviewing each file to ensure accuracy.


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

raw_content: There were multiple prescription medications stored in a zip lock bag.

Correction Narrative: All medication was observed in their own containers.


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

raw_content: During the investigation, information was obtained, that two children in care engaged in hitting one another in three different occurrences before staff members were made aware.

Correction Narrative:
On 11/28/2023 RCCR received an email from the agency of compliance plan:

The caregivers at Haven of Rest Care Home will have additional training in the supervision of children with high-risk behaviors to ensure they are knowledgeable and well-prepared to intervene when unsafe and high-risk behaviors occur.

Supervision policies will be reviewed and discussed during each monthly staff meeting.  Service Plans for each child will be reviewed and discussed as necessary at the meetings.  Professional help from outside organizations/mental health services, and licensed experienced professionals (Behavioral Therapist, LPC, etc) will be sought as additional resources to help meet the training needs of staff.


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

raw_content: A current staff member s background check was inactive as of 5/16/2023.

Correction Narrative: The operation submitted a background check for the employee. It was returned clear without conditions.


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: A staff member did not implement recommended techniques for discipline when engaging a child in care.

Correction Narrative: An email was received from the Executive Director stating they will ensure that all parties involved in a service plan will review and sign.  The staff have been reminded of this procedure. All service plans have been reviewed to ensure they are all corrected, and all children have been given a copy and reviewed with them.


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

raw_content: The service plan for one out of two child files was not signed by the child.

Standard Risk Level: Low

Correction Narrative: Operation owner/director emailed the updated service that was signed by the child.


summary: 748.863(b) - Pre-Service Training-Document the completion of each pre-service training requirement in the appropriate personnel record

raw_content: Two staff files did not include documentaiton of total required pre-service training hours.

Correction Narrative: Operation owner/director emailed pre-service training certificates for the two staff. The training certificates document the required pre-service training hours.


summary: 748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days

raw_content: One staff did not complete EBI pre-service training requirement hours.

Correction Narrative: Operation owner/director emailed the training certificate for the staff. The certificate shows that the employee completed the required EBI training hours.


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 were reviewed and two employees had pre-drug screening after their hire date. The hire dates that arevreported in the file are 10/22/2020 prescreening drug test 07/11/2021 and 07/17/2021.

Corrected at Inspection: Yes


summary: 748.153(3)(B) - Notification - New controlling person

raw_content: There is no controlling person form for the administrator. The administrator date of hire was 10/22/2020.

Correction Narrative: Operation owner/executive director emailed a copy of the completed controlling person form for the administrator. The administrator was added to the controlling person list.


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

raw_content: medication records did not have actual count of medication present.

Category: Medication

Correction Narrative: Operation administrator emailed a copy of the updated med log which now includes the medication count remaining.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: Staff must have TB test or  chest ex-ray before working with children in care and provide documentation.

Correction Narrative: Ms. May emailed a copy on 9-1-2021 of the TB chest X-ray results for Mr. May to RCCR Inspector Alcy Morgan. A copy of this document will be uploaded to the SharePoint.


summary: 748.563(c) - Professional level service provider-must meet specific educational and professional qualifications

raw_content: Professional level staff must have the education and work experience to perform their job duties

Category: Personnel

Correction Narrative: On 6-9-2021, Ms. May submitted an updated Job description with position change for Mr. Charles Sanders with his signature of acceptance of the position. Document will be uploaded.


summary: 748.1205(a)(4) - Admission Documentation-Includes names, addresses, telephone numbers of siblings

raw_content: A record for the child to be able to commincate with his/her siblings.

Correction Narrative: On 4/19/2021, Ms. May provided a copy of the signature form that will be provided to children  to list their contacts to enable them to make contact with their siblings and have a copy placed in their file when her operation is able to start placing children.


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

raw_content: One employee file reviewed did not contain verification that the employee met the educational requirement

Category: Reports and Record Keeping

Correction Narrative: Ms. May emailed a verification email from her previous college that stated that documents requested related to her degree could not be obtained due to the school being closed. The degree was obtained in 1969 from Salendine Nook which his outside of the United States.


summary: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

raw_content: A copy of the child"s orientation was not found in the file.

Correction Narrative: On 4/19/2021, Ms. May provided a copy of the child right form that will be provided to children and placed in there file when her operation is able to start placing children.


facility_name: Make A Way Residential Treatment Center

summary: 745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone

raw_content: Background check was not submitted for a caregiver at the time of hire for the corresponding operation.

Correction Narrative: The background check was accidentally submitted twice at the Make A Way RTC 2.0 instead of once at Make A Way RTC.  The LCCA promptly submitted the required background check for the caregiver to ensure compliance and safety.  The LCCA will implement a standardized hiring checklist that will include verification of background checks for each operation to prevent similar issues in the future.  Regular audits will be scheduled to ensure adherence to these protocols by the LCCA. The background check was verified in CLASS.


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: At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.

Correction Narrative: A new bed has been ordered and was delivered on 8-30-24.  A receipt was sent for proof of purchase.


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

raw_content: At the time of inspection, 1 prescription medication for a child in care was administered but not documented.

Correction Narrative: The direct care staff member will take a refresher training on med administration. The trainer will focus on signing and documenting the medications once given to children in our care. The direct care staff member will sign a training roster and will be given a certificate at the end of the training.


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

raw_content: At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.

Correction Narrative: The direct care staff member will take a refresher training on med administration.  The trainer will focus on signing and documenting the medications once given to children in our care.  The direct care staff member will sign a training roster and will be given a certificate at the end of the training.


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

raw_content: At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.

Correction Narrative: The closet in room 8 has been repaired to where the electrical wires are no longer exposed and not accessible to the children in our care.


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

raw_content: During the course of the investigation it was determined that kids are subjected to profanity by staff.

Correction Narrative: During the inspection, children were interviewed, and two out of four children stated staff members do not curse. Two out of four children admitted to hearing staff members curse, but stated staff does not curse at them. Staff members were interviewed and understand that cursing and profane language is strictly prohibited. The operation has a no cursing policy.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.

Correction Narrative: During the inspection, children were interviewed, and two out of four children stated they had never been restrained, nor have they witnessed any restraints. Two out of four children admitted to being restrained and stated they were counseled with and were not injured. Staff were interviewed and understand when to conduct a restraint and stated they perform cradle restraints only. Staff members are trained to perform restraints when warranted.


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

raw_content: One staff member admitted to falling asleep while counted in ratio.     A physical altercation occurred between three residents. The incident was confirmed in child interviews.

Correction Narrative: Staff and children were interviewed. More children than not stated that staff members do not sleep while supervising children. The employee that admitted to falling asleep while counted in ratio was terminated. The operation stated they have a no sleep policy.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: Child in care was restrained with arms behind the back.

Correction Narrative: Interviewed 3 of 3 children present in the home. Children reported not having been restrained nor witnessing restraints. Interviewed 2 staff members who are responsible for conducting training on restraints, reported that staff were trained in EBI refresher training last week.


raw_content: A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.

Standard Number / Description: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

Correction Narrative: The agency has responded with an email as well as a face to face with staff for the protocol on emergency behavior intervention for restraints and will continue to keep all staff trained and refreshed. The monitoring inspection #3928136 was completed during this Follow-up the agency provided documentation on how they will continue to keep adhere to the minimum standards.


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

raw_content: During the inspection,  2 of 4 children's files were missing dental records.

Category: Organization and Administration


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

raw_content: During a review of the records I found that EBI had not been reported for the first quarter of 2022.

Category: Emergency Behavior Intervention

Correction Narrative: A review of the EBI reporting confirmed that EBI was reported for the period of concern. Staff have an understanding of the requirement and will ensure ongoing timely reporting.


summary: 748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation

raw_content: Policies did not include directions for egress

Category: Safety and Emergency Practices

Correction Narrative: An email correspondence was received containing the directions for egress. Compliance has been met.


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

raw_content: Policies didn't include diagram  designating location inside operation to shelter from threatening weather.

Correction Narrative: An email correspondence was received containing the diagram designating a location on the inside of the operation to shelter from threatening weather.


facility_name: Fostering Life Youth Ranch, LLC Meraki

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

raw_content:
During a review conducted on November 25, 2025, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan.

The heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citation issued on November 10, 2025, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:

Your operation received a medium high weighted citation in a pattern/trend category on November 10, 2025. Specifically, the operation was cited for 748.2151(c)(5) Medication record - must include date (day/month/year) & time each medication was administered. The operation met compliance on November 24, 2025.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with medium high and/or high weighted licensing citations.

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

Correction Narrative: An HM extension was approved effective 11/25/25.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 5/26/2026.


raw_content: Staff failed to intervene in a timely manner, resulting in child in care sustaining an injury to the face.

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


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

raw_content: A physical altercation occurred between two children was not documented.

Correction Narrative: Email received from the operation providing documentation of staff that were retrained, their certificates, and the assessments for the employees with multiple investigations,


raw_content:
During a review conducted on May 20, 2024, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan.

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.

Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having open investigations.

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

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

Correction Narrative: An HM extension was approved effective 5/20/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 11/21/2024.


raw_content: During a short personal restraint a child received carpet burn to his face and his elbow. The child was taken to the doctor due to injuries sustained.

Standard Number / Description: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

Correction Narrative: The operation emailed their compliance information stating the staff involved in the investigation was retrained on SAMA before he could work his next shift and he was placed on a safety plan. All staff were verbally reminded to minimize the risk of harm in a containment. On 07/18/2023 a in person follow-up was completed as part of inspection #3958439.  The operation stated that the staff is still on a safety plan and before the end of July they will determine what the next steps will be for staff, such as continued ongoing training with a new program they are starting.  They will discuss if staff's role should be monitoring EBIs instead of conducting them.


facility_name: Armanis House Inc. Residential Care

summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: Staff records were reviewed and the tuberculosis screening results were not located in the file.

Correction Narrative: The operational staff provided a copy of the the missing TB shot and stated that goig forward that he remedy will be to ensure that the staff files are complete before new hires first date of hire. HR will be sure to check before the first day of the New Hire on the floor, the administrator will look over and sign off on the files.


summary: 745.651(2)(A) - Background Check Validation - Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content: The operations peoples list for background checks was validated last on 2/26/25.

Correction Narrative: The peoples list was validated on 6/9/25. The status of the validation of the peoples list will be checked monthly.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: Serious incident reports were reviewed which did not indicate the roles of the staff involved in the incidents.

Correction Narrative: The remedy for deficiency is to ensure that the option for staff to write their name and title is present on the serious incident report forms. Before filing, supervisors will be responsible for looking over the paperwork ensuring that it has been filled out correctly. Staff will also be scheduled to attend documentation training.


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: Staff files were missing the required reference checks and or the date that the reference check was completed and the outcome of the reference check.

Correction Narrative: The deficiency will be address, going forward by conducting internal file audits, to make sure that each employee's record has references, names, relation, the date it has been completed, the information obtained as well as who it was completed by.


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

raw_content: The thermometers in the freezer and refrigerator are not functioning properly to give an accurate temperature reading.

Correction Narrative:
A photograph of the new themometer was provided. A compliance corrective action plan was also proided stating the following:
The remedy for deficiency to order new food thermometer for both the refrigerator and the freezer.

To further address this issue is moving forward staff will add this to the quarterly house check to ensure that the device is working and reading correctly.


summary: 748.605(c) - Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders

raw_content: Based on the documents/credentials provided for verification, the treatment director doesn't meet the requirements for emotional disorders.

Correction Narrative: We have resolved this deficiency by hiring a Treatment director. The treatment director has been certified by the Texas Education Agency in Special Education, has a master's degree in human services field, and has over 20 years of experience working with children with emotional disorder, intellectual disabilities or autism spectrum disorder. Our treatment director has over 3 years of experience working with GRO's and RTC's.  We will continue to have a treatment director at our facility, ongoing from 9/26/2024. We will stay in compliance by always having a treatment director on staff. To prevent similar citations in the future, the license childcare administrator will always update employees file to make sure we are in compliance.


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

raw_content: According to the information in a child initial service plan, the child was admitted on 1-5-24 and the date initial service plan was completed on 8-2-24 which is about 210 days after placement.

Correction Narrative: The remedy for the deficiency is to completed all initial service plan within 45 days after placement of any child being place at Armani House in a timely manner as required by minimum standard.


summary: 748.1337(b)(1)(L) - Initial Service Plan-Include date service plan was developed and completed

raw_content: 3 children service plan reviewed did not have the date the service plan was developed.

Correction Narrative: The remedy for the deficiency is to have all service plan participants complete the participants page with their names, date, role and signature to confirm their participation in the meeting.


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

raw_content: 3 children service plan reviewed did not have the names and roles of the service plan participants.


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

raw_content: 3 children service plan reviewed did not have signatures of service planning team members.

Correction Narrative: The remedy for the deficiency is that all service plan participants complete the participants page with their names, date role and signature to confirm their participation in the meeting.


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

raw_content: One child's date of admission is missing in the Unauthorized absence log

Correction Narrative: The remedy for the deficiency is to complete all unauthorized absence logs as required according to minimum standard. Armani House will review all authorized absences log for accuracy.


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

raw_content: Residents left the facility and went out with an unknown male without the knowledge of staff on duty. Residents left the facility through the Neighbours fence, and they stated during interview that staff did not see them leave the facility.

Correction Narrative: The remedy for the deficiency is to conduct a supervision refresher training for all direct care staff by 9-15-24, and all staff are providing supervision of all resident at all times which include auditory and visual contact.


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: Operation staff present at the operation does not a drug screen in employee file.

Correction Narrative: Staff files were reviewed to ensure all updated drug screens have been entered into file and have been completed prior to hire date. Staff interviews were completed to ensure this was completed.


summary: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

raw_content: Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.

Correction Narrative: New drug tests were observed and stored at the office. Drug screens are supplied by operation.


summary: 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions

raw_content:
During the inspection, it was observed that multiple
items in the freezer were not properly labeled with expiration dates after being removed from its original packaging.

Correction Narrative: During the follow up inspection, I observed the food packaging in the refrigerator to include expiration dates.


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

raw_content: During the inspection, in the bathroom down the hallway near the living room on the left side, the left knob on the first bathroom sink turns, but does not produce any water.

Correction Narrative: During the follow up inspection, I observed the bathroom faucet to be repaired and the operation provided a work order.


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

raw_content: Operation staff files reviewed did not have completed references for staff and volunteers present at the operation.

Correction Narrative:
Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.

On 5/22/2024 Operation reported moving forward they will have a checklist of what is required to be in each personnel file and have routine audits to ensure compliance is achieved and maintained.


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: Operation staff present at the operation does not have notarized affidavit but was signed by employee in May, 2024.

Correction Narrative:
Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.
On 5/22/2024 Operation reported moving forward they will have a checklist of what is required to be in each personnel file and have routine audits to ensure compliance is achieved and maintained.


Standard Number / Description: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

Deficiency Narrative: Operation staff files do not include correct drug screens to show the required screening areas and did not include how operation confirmed false positives below 2% and false negatives below 8% on all drugs screened.


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

raw_content: Operation used a form for serious incident reporting that did not include required information per minimum standards.

Correction Narrative: Inspector received compliance plan from operation stating that moving forward the operation will update the in-house record to ensure that the documentation meets the minimum standard guidelines for the DFPS. Age, gender, DOA are modifications that have been added to the documents. Each month on the 1st of the month the documents are transferred from the daily personal record of the resident to the client records. Office manager will then complete an audit to ensure that all records are filled out correctly for the previous month, signed, and are present.


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: Operation staff/volunteer present at the operation with access to children in care did not have a completed TB screening. Another staff file did not have a TB test completed within 30 days before or after hire date.

Category: Child Care

Correction Narrative: Inspector received compliance plan from operation stating that moving forward they will ensure that all persons whether residents or staff will have a documented tuberculosis screening that was conducted as recommended by the Center for Disease Control, within 30 days before or after beginning to live, work, or volunteer at Armani House this will be completed by operation staff conducting audits of the files on a quarterly basis.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: Staff present at the operation did not have a current job description to indicate their role as well as official date of hire for type of position.

Correction Narrative: Operation will ensure that moving forward that for each employee, the personnel record will include A notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code this will be completed by operation staff conducting quarterly audits.


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: Operation staff informed licensing they did not have debriefing documentation for children who eloped from care.


summary: 748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years

raw_content: Child File had a medication log that was not completely filled out and did not list the reason why medication was given.


Standard Number / Description: 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

Deficiency Narrative: Operation staff present at the operation does not a drug screen in employee file.


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

raw_content: Operation staff files reviewed did not show employment history for the last five years and did not indicate if staff did not have employment history prior to working at the operation.


summary: 748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement

raw_content: A child file had identified high risk behaviors, however there was no documented safety plan that would be implemented on how to address the behaviors.

Correction Narrative:
3/28/24, Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.
On 4/11/2024 compliance plan received from operation stating in an effort to remedy this deficiency operation will ensure that children in care with high-risk behaviors will have safety plans developed and implemented.  Safety plans will be tailored specifically to each child. The responsibility for this fall upon the LCCA. They will be implemented and measured by the DFPS minimum standard guidelines. Residents will be under close observation during safety plans.


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

raw_content: One employee file had psychotropic medication training that expired in January 2024.

Correction Narrative:
3/28/24, Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future. Certificate for psychotropic medication for missing employee file was provided on this date.
On 4/11/2024 Inspector received email from operation stating in an effort to remedy this deficiency and prevent future re-citation from occurring; operation will ensure that all staff that will be on duty during medicine time will be trained and have certificates in each employee's binder.  A employee checklist has been established and this training has been included in the list. We have also set up a calendar reminder to ensure that all staff gets a reminder 60- and 45-days prior to training renewal dates.


summary: 748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid

raw_content: One employee file did not have a CPR/First Aid certification.

Correction Narrative: Inspector received email with compliance plan from  operation staff which stated that moving forward the operation will ensure that all employees received and/or are current on CPR training prior to being employed and that a calendar was provided.


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

raw_content: A child file did not have a preliminary service plan completed within the required time frame.

Correction Narrative:
3/28/24, Inspector received compliance plan from LCCA however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.
On 4/11/2024 Inspector received updated compliance plan from operation stating that moving forward they will ensure that the plan commitments are completed within the first 72 hours of receiving the resident. This is completed by completing the intake checklist step-by-step from the time we get transportation confirmation. We also have set up calendar reminders to make sure everything has been set up in a timely manner. The LCAA is responsible for this.


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

raw_content: One employee file had expired normalcy training.

Correction Narrative: Inspector received email from operation staff with compliance plan which stated moving forward the operation will work to ensure that all staff and employees have normalcy training before being allowed to work. This item will be placed on a checklist in the employee's file and has also been added to the calendar 30 days prior to the expiration date and a reminder email sent to the staff.  Inspector also received copy of normalcy certificate for missing file.


Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Deficiency Narrative: Operation used a form for serious incident reporting that did not include required information per minimum standards.

Correction Narrative:
3/28/24, Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.
On 4/11/2024 Inspector received email from operation staff stating that in an effort to remedy this deficiency is to update the in-house record to ensure that the documentation meets the minimum standard guidelines for the DFPS. Age, gender, DOA are modifications that have been added to the documents. Each month on the 1st of the month the documents are transferred from the daily personal record of the resident to the client records. Office manager will then complete an audit to ensure that all records are filled out correctly for the previous month, signed, and are present.


summary: 748.931(c)(2) - Annual Training- Childcare administrators, PLSP's, treatment directors and case managers who hold a prof. license must have 2hrs transportation.

raw_content: One employee file did not have transportation training.

Correction Narrative:
3/28/24, Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how they will be working to mitigate citation from re-occurring in the future.
On 4/11/2024 Inspector received email from operation staff stating in an effort to remedy this citation and reduce the possibility of future re-citations occurring operation will ensure that the transportation training has been completed and that before staff are allowed to drive the vehicle, they must complete training, as well as do a ride along with senior staff to ensure things learned in training are implemented and properly applied. An employee checklist has been established and this training has been included in the list. We have also set up a calendar reminder to ensure that all staff gets a reminder 60- and 45-days prior to training renewal dates.


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

raw_content: A child file did not have a documentation of notice being provided to their guardian of service plan meeting.

Correction Narrative:
3/28/24, Inspector received compliance plan from operation staff however, inspector returned as compliance plan did not address in detail how the operation will be working to mitigate citation from re-occurring in the future.
On 4/11/2024 Inspector received email from operation stating the operation plans to ensure the letter inviting the parents to the meeting is sent out 7 days after the arrival. The meeting will be scheduled for day 14 of the resident's arrival. This has been added to the intake checklist. This will fall under LCCA responsibilities.


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

raw_content: A service plan that identified a child as having high risk behaviors for AWOL, self-harm, and harm to others stated she did not require supervision outside the home and included no supervision requirements for the child while outside the home.

Correction Narrative:
Inspector received email with compliance plan for operation; however, Inspector returned compliance plan to operation for correction as it did not adequately detail how operation would address safety plans being created for high-risk behaviors for children in care in the child's plan of service.
On 4/23 and 4/25 Inspector sent email to operation inquiring as to a status update on the compliance plan corrections.
On 4/25/2024 Inspector received email from operation stating The remedy for deficiency is to review each resident file thoroughly. We will then update the staff to ensure that they all are aware and take into account each resident's high-risk behaviors and history. This information will determine the level of supervision inside and outside the home. The operation will include in all resident's initial service plans who have a history of sexual abuse (i.e. victim or predator).  Armani House will ensure a safety plan will be implemented for residents along with the level of supervision all staff must provide and document on progress notes. All attachment A information will be provided to all Armani House staff to ensure proper supervision. Armani House will ensure that all staff will be informed of resident's service plans by conducting quarterly training. Staff will be informed on where to
locate information on which residents are victims or perpetrators and will be trained on what type of supervision will apply to the resident throughout the 24-hour day.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content: A person identified by the Administrator as a peer-to-peer support/volunteer was present at the operation on 2/11/24 and one other time prior, without a background check. Another citation related to this deficiency within the next 6 months may result in an additional penalty and other enforcement actions.

Correction Narrative: On 04/12/24, email provided by operation stating the following staff member did receive their background check approval and is no longer in pending status. All volunteers will have folder that includes DL and cleared background checks.


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

raw_content: Operation has not had an unannounced fire drill in the last 6 months.

Correction Narrative:
On 2/16/24, compliance plan was received by operation staff. Additional information was requested and received on 2/23/24, operation was able to show compliance.

The remedy for deficiency is to keep in compliance with the regulation guidelines. An evacuation fire drill will be completed at random within the 6-month guidelines. Armani's House will be responsible for ensuring this is completed and in the file. All staff have been advised and the dates have been added to all calendars and added to all quarterly meetings. This will also be added to the quarterly checklist.


summary: 748.721(a) - Volunteer personnel record-The operation must maintain a personnel record for each volunteer

raw_content: A volunteer was observed to be at the operation did not have a personnel file.

Correction Narrative:
On 2/23/24, operation staff was able to provide additional documentation to show how they are compliance for volunteer staff record.

2/16/24, compliance plan was received stating a file was created but no additional information. This was referred back to the operation for more information.


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

raw_content: A serious incident in which a resident became physically aggressive towards other staff and sustained an injury was not documented on a serious incident report.

Correction Narrative: Inspector received email from Administrator with compliance plan for citation.  Compliance plan listed that a form 2991 would be used along with an attachment of what constitutes a serious incident.


summary: 748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director

raw_content: Operation has 50 % of their population as treatment services and do not have a treatment director.

Correction Narrative:
3/21/24, operation was able to provide documentation to show staff was able to meet the requirements for treatment director only for Emotional Disorders as transcripts were provided to verify the education. The operation is still needing a treatment director for IDD and PDD services should they have children in care placed at their operation who have this diagnosis.

2/26/24, email received from operation stating a treatment director was hired and meets the criteria for treatment services. There was no additional information therefore, additional information was requested to verify.


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

raw_content: Two employee files did not have reference check screening.

Correction Narrative: On 2/16/24, email was received by operation with a compliance plan stating the operation will complete pre-screening reference checks for all staff and will ensure it will be obtained, filed and signed off by operation prior to employment.


summary: 748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator

raw_content: A volunteer did not have a signed and dated statement to report abuse and neglect.

Correction Narrative: LCCA provide proof of signed abuse and neglect statement for volunteer via document.


summary: 748.4651(b) - Pre-Service Training- caregiver not meeting 40 hr experience must be supervised at all times by another qualified caregiver

raw_content: Two employee files did not have required 40 hrs of experience or supervised experience.

Correction Narrative:
On 2/26/24, additional documentation for staff member was provided showing all completed training.

On 02/23/24, additional information and documentation was provided to show one of the two staff met the required training.

On 2/16/24, compliance plan received stated two staff had the completed trainings required but no other documentation to show when and how this was completed, therefore, additional information was requested.


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

raw_content: Serious incident report did not contain necessary information required on form regarding child's gender and date of admission.

Correction Narrative: Inspector received email from LCAA with compliance plan stating they would be adopting form 2991 to use for serious incident reports.


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

raw_content: Operation has not had an unannounced severe weather drill in the last 6 months.

Correction Narrative:
2/16/24, compliance plan received from operation staff related to the following citation. Additional information was requested and received on 2/23/24, operation was able to meet compliance.
The remedy for deficiency is to keep in compliance with the regulation guidelines. A severe weather drill will be completed at random within the 6-month guidelines. Armani's House will be responsible for ensuring this is completed and in the file. All staff have been advised and the dates have been added to all calendars and added to all quarterly meetings. This will also be added to the quarterly checklist.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: Two staff files did not have a current TB test.

Correction Narrative: Inspector received email with updated TB tests for both employees.


summary: 748.105(7) - Personnel Policies - Ensure that personnel policies comply with background check requirements

raw_content: Updated background check policy was not completed and approved at time of inspection.

Correction Narrative:
Extension granted as updated policy is pending program specialist approval.

On 10/09/23, inspection was completed for second initial therefore, policies were reviewed and sent to PS however, pending for approval. Submitted for review on 10/07/23. No follow-up form was created as inspector was at the operation for second initial inspection.


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

raw_content: Fence was observed to have exposed nails.

Category: Physical Site

Correction Narrative: Inspector received pictures of corrected physical site issues.  Nails were no longer shown to be exposed.


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: Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Correction Narrative: Inspector received drug test results for employee.


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

raw_content: Operation did not have a current health inspection.

Correction Narrative: Operation will obtain a current health inspection or a letter stating why a health inspection is not needed at a facility/operation. Compliance Monitoring will be placed in the operation files with the date. Operation will also use Texas Health and Human Services Form 4004 Residential Child Care Licensing Environmental Health Checklist


summary: 745.4151(c)(4)(C) - Mandatory drug testing-employee that is subject of child abuse or neglect investigation must be drug tested within 24 hours of notification by DFPS

Deficiency Narrative: Staff hired at the operation currently does not have a pre-employment drug screen for the operation related to application.

Correction Narrative: New employees will schedule a drug test screening during orientation. The LCCA will audit staff files annually and have a calendar notification reminder. Compliance Monitoring will be place in all staff files with date of drug testing.


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: 2 of 2 staff files reviewed did not include in the signed statement for abuse, neglect and exploitation to include specific instructions for hotline and notifying operation.

Correction Narrative: During the new employee orientation, reporting Serious Incidents, & Suspicion of Abuse, Neglect, or Exploitation will be discussed. The LCCA/ Shift Supervisor will show the new employees where the phone number and the website are in the facility.  The LCCA/Shift Supervisor will have all new employees sign a document affirm that they have read and understand the Reporting of Serious Incidents for Armani's House and will adhere to the policy, they will also inform the LCCA of any Reporting Serious Incidents and failure not to adhere to this policy could mean the termination of employment or other disciplinary actions.  The LCCA will sign their own name and check for the employees who have signed their name. The LCCA will audit staff files annually and have a calendar notification reminder. Compliance Monitoring will be placed in all staff files with the date.


facility_name: Open Hearts Children and Family Services - The Village

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

raw_content: On two separate occasions, a child in care sustained head injuries when they hit their head on concrete and the tile floor. The head injuries were described by staff as bleeding and "a good size bump." Staff failed to take the child to be evaluated by medical professionals.

Correction Narrative: The operation was notified of HHSC's intent to deny a permit on 8/5/2024. The operation has no children in care and is no longer allowed to operate. A follow up inspection was conducted at the operation on 8/14/2024. The operation appears to be closed, and there does not appear to be any staff or children present at the operation. The permit holder was contacted via phone call during the inspection. The permit holder confirmed that all children have been discharged, and there are no staff working at the operation. The permit holder was not able to meet licensing at the operation at the time of the inspection. The permit holder contacted two former operation staff to see if they could meet licensing at the operation. Neither staff was available. The permit holder was provided with instructions on how to mail the operation's permit to licensing.


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

raw_content: The operation's serious incident report policy states that employees shall report serious incidents to the abuse hotline, without delegating the reporting to another party. Based on the information provided, staff are required to only document serious incidents so management staff can review the incidents and report to the hotline when deemed necessary. Therefore, operation staff failed to follow their written serious incident reporting policy.


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: Of the five serious incident reports reviewed, four of the incidents were related to children in care sustaining injuries that required medical attention. Three of those incident reports did not have any documentation for any type of medical intervention by operation staff or medical professionals. Additionally, the fifth serious incident report related to a child being in possession of a vape pen had no type of invention or resolution documented for the incident.


summary: 748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.

raw_content: During two separate incidents, two children in care sustained injuries that required medical treatment. These incidents were not reported to the children's caseworkers.


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

raw_content: During two separate incidents, two children in care sustained injuries that required medical treatment. These incidents were not reported to licensing.


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

raw_content: During the walk-through, there was a roll of sausage in the refrigerator that was not properly packaged and stored. This was corrected at inspection.


summary: 748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent

raw_content: After conducting an investigation inspection, Licensing was unable to exit with the administrator. Two attempts were made to contact the administrator by telephone. It was reported by the case manager the administrator was out due to an eye procedure, and she was not aware of who was left in charge.

Correction Narrative: The operation was notified of HHSC's intent to deny a permit on 8/5/2024, and as of this date, the operation has not requested an administrative review. The operation has no children in care and is no longer allowed to operate. A follow up inspection was conducted at the operation on 8/14/2024. The operation appears to be closed, and there does not appear to be any staff or children present at the operation. The permit holder was contacted via phone call during the inspection. The permit holder confirmed that all children have been discharged, and there are no staff working at the operation. The permit holder was not able to meet licensing at the operation at the time of the inspection. The permit holder contacted two former operation staff to see if they could meet licensing at the operation. Neither staff was available. The permit holder was provided with instructions on how to mail the operation's permit to licensing.


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 walk-through, there were unlocked chemicals under the kitchen sink, in the downstairs bathroom, and in the laundry room.

Correction Narrative: CEO sent email stating that the children had left the temporary location and went back to the operation.


summary: 748.1339(a) - Initial Service Plan-Service planning team must develop the service plan

raw_content: The operation failed to submit a correction plan or proof of corrections addressing the service planning team involvement in the development of a child's service plan by the compliance date.

Correction Narrative: CEO sent email with the following corretions: Service Plan re-training with Case Manager Xaley Woolfolk. To ensure that all persons on the treatment team are notified within 14 days. We will ensure the 14-day notice is completed and sent to appropriate parties and we will maintain a record of it. We also will send completed copy of the service plan and request signatures within 10 days after completion if the parties did not participate in the original service planning day..


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: The operation failed to submit a correction plan or proof of corrections addressing the physical site by the compliance date.

Correction Narrative: CEO sent email witth the following corrections: Due to having to relocate the facility July 16th - July 26th; this task was paused. The repair company was at the facility on July 16th to assess the work to be done, they did bring materials on this date and had to leave when we were notified to relocate. Currently the repair crew will reconvene on 7/31/24. The repair crew arrived while the inspector was at the facility.


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

raw_content: The operation failed to submit a correction plan or proof of corrections addressing the direct care staff yelling at a child in care by the compliance date.

Correction Narrative:
Retraining all staff to address appropriate and effective discipline. Review the Discipline Policy and Facility Staff will sign. Scheduled for 7/31/2024.
Update: Sheree Holmes conducted the discipline training on 7/31/24. Gayun Matthews, Xaley Woolfolk, Krystle Johnson, Marie Higgs, Patricia Morris (new hire), and Thelesha Peterson (possible new hire) were present. A second training will be held on Tuesday, August 6,2024 for the remaining staff to attend. Please see the attached sign-in sheet and acknowledgement sheets. Training certificates will be stored in each person s file by 8/2/2024 for 7/31/2024 attendees and within 48 hours after the training for those attending on 8/2/2024.


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: The operation failed to submit a correction plan or proof of corrections addressing the caregiver's TB test results by the compliance date.

Correction Narrative:
Krystle Johnson is scheduled for a new TB Test 7/30/24 to replace her initial results.
Update: Krystle was able to obtain a copy of her original T.B. test. Please see attached


summary: 748.303(e)(1)(B) - Serious Incident-Report to parents no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary

raw_content: The operation failed to submit a correction plan or proof of corrections addressing the operation failing to report to parents of a reportable incident by the compliance date.

Correction Narrative:
Retraining on Serious Incidents and Reporting. When and Who to report to with Time frames. Scheduled for 7/31/2024
Update: Sheree Holmes conducted the serious incidents and reporting training on 7/31/24. Gayun Matthews, Xaley Woolfolk, Krystle Johnson, Marie Higgs, Patricia Morris (new hire), and Thelesha Peterson (possible new hire) were present. A second training will be held on Tuesday, August 6,2024 for the remaining staff to attend. Please see the attached sign-in sheet and acknowledgement sheets. Training certificates will be stored in each person s file by 8/2/2024 for 7/31/2024 attendees and within 48 hours after the training for those attending on 8/2/2024.


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

raw_content: During interviews it was determined the three victims discovered a wine bottle in the refrigerator, however the four staff interviewed denied being aware of the wine bottle at the location.  It was noted the bottle of wine was in the refrigerator within reach of children for three days.


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

Correction Narrative:
An opened bottle of wine was observed in a refrigerator accessible to children in care during a walkthrough of the operation's temporary location.

An inspection was completed at the temporary location and there was no bottle of alcohol or any other prohibited items at the facilityl. This standard was found compliant.


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

raw_content: The operation failed to provide corrections for this citation given on 7/9/2024. This is a result of medication not being stored in a locked container during the time the children were being transported to a relocation center.

Correction Narrative: TVOH will ensure to store medication in a locked container during possible transport to a temporary location. TVOH will utilize lock boxes that are currently at the facility.  TVOH reviewed this standard with Case Manager and DCS lead.


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

raw_content: The operation failed to provide corrections for physical site issues that were found during an inspection.

Correction Narrative: The landlord, has been notified of the items in need of repair.  The work is scheduled to begin on 7/16/2024.  The facility will be assessed monthly and noted repairs will be listed on the monthly facility check list moving forward.


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

raw_content: The operation failed to provide corrections for this citation given on 7/9/2024. The operation's administrator has not been present and provided on-site duties.

Correction Narrative: TVOH has a 30-day plan to have our current case manager become the primary administrator and our current administrator to serve as a back-up.  During the 30-day plan our current administrator will work to meet the 30-hour requirement for this standard. We will have a sign-in sheet for the administrator to log her hours and a weekly report will be submitted.


raw_content: The operation failed to provide corrections for this citation that was issued on 7/9/2024. This citation was given due to the mold being present at the operation.

Standard Number / Description: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

Correction Narrative: TVOH has been working with our landlord to address the non-harmful mold, penicillium.  Servpro in Texarkana, TX will conduct the non-harmful mold.  We are waiting for the service date.  Servpro noted they were behind due to the recent weather issues in the area.


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

raw_content: The operation failed to submit corrections exhibiting completion of the repairs to the drywall in the bedroom and rec room or the securing of the bare nail in the resident wall by the compliance date.

Correction Narrative: The operation submitted proof of correspondence with the repair team scheduling repairs to begin on Tuesday (7/16/24).  The operation submitted repair requests to the landlord and has no control over the completion of those work requests.  This scheduled maintenance brings this standard into compliance.


summary: 748.3443(a)(3) - Food Preparation-Food items must be protected from contamination

raw_content: The operation failed to submit a correction plan or proof of corrections addressing the uncovered food stored in the refrigerator and pantry by the compliance date.

Correction Narrative: The operation purchased disposable containers that will be used to store food no longer in its original packaging.  A meeting was held with all residents and staff discussing the importance of using appropriate storage containers to prevent possible contamination.  Staff will conduct daily checks to ensure uncovered food is not stored in the refrigerators.


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

raw_content: The operation failed to submit evidence of thermometers being installed in all freezers and exhibiting temperatures below 0 degrees Fahrenheit by the compliance date.

Correction Narrative: The operation purchased thermometers for all refrigerators and freezers.  Administration has accepted responsibility for ensuring the use of these thermometers and will monitor on a monthly checklist.


summary: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: The operation failed to submit proof of the repair or removal of the deep freeze unit by the compliance date.

Correction Narrative: The operation has removed all food from the damaged deep freezer and removed it from service.  It has been disconnected and marked with a sign stating "Please Do Not Use" until it can be properly removed from the facility.


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

raw_content: The operation failed to submit proof of a thermometer reading 40 degrees Fahrenheit or below in the mini fridge in the kitchen by the compliance date.

Correction Narrative: The operation purchased a thermometer for the minifridge.  Administration will monitor the presence and use of the thermometers on a monthly checklist.


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

raw_content: Two direct care staff failed to provide adequate supervision due to them sleeping while on shift supervising children in care.

Correction Narrative: The operation was notified of HHSC's intent to deny a permit on 8/5/2024. The operation has no children in care and is no longer allowed to operate. A follow up inspection was conducted at the operation on 8/14/2024. The operation appears to be closed, and there does not appear to be any staff or children present at the operation. The permit holder was contacted via phone call during the inspection. The permit holder confirmed that all children have been discharged, and there are no staff working at the operation. The permit holder was not able to meet licensing at the operation at the time of the inspection. The permit holder contacted two former operation staff to see if they could meet licensing at the operation. Neither staff was available. The permit holder was provided with instructions on how to mail the operation's permit to licensing.


raw_content: During the inspection, I observed an uncovered drink cup containing fluid in the mini-fridge and a container of animal crackers with no lid, leaving both items intended for consumption unprotected from contamination.

Standard Number / Description: 748.3443(a)(3) - Food Preparation-Food items must be protected from contamination


raw_content: During the inspection, I observed the deep freezer in the pantry area that does not close and containes food items lacks a thermometer and internal temperature cannot be verified.

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


raw_content: During the second follow-up inspection, I observed the damage to the drywall in the recreation room remains unrepaired, a cracking drywall patch in a bedroom remains unrepaired, and an unsecured nail in a bedroom remained.  The previous resident of the room had recent self-injurious behaviors, and the room is currently occupied by a new resident without the nail being removed.  These errors were not corrected from the preceding follow-up inspection.

Standard Number / Description: 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 second follow-up inspection, I observed the freezer unit in the pantry area does not close properly, resulting in frost ringing the unit and the freezer not sealing properly.  The freezer has food items stored within.

Standard Number / Description: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair


raw_content: During the second follow-up inspection, I observed a mini-fridge in the kitchen still lacked a thermometer.

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


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: During the initial inspection, four of four personnel records reviewed, were lacking 1 hour of annual suicide prevention training. During the follow up inspection completed on 7/8/2024, the four personnel records still did not have the annual suicide prevention training.

Correction Narrative: On 7/15/2024, the operation's Executive Director advised via safety plan, all staff will complete the required DFPS Suicide Training by July 13, 2024. This training is aligned with the requirements mentioned in our policy.


summary: 748.911(b)(3)(A) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi/Adult CPR if serving children 0 to 17.

raw_content: During the initial inspection, three of four personnel records reviewed did not have the correct CPR training to serve pediatrics/adult as required by Minimum Standards. During the follow up inspection completed on 7/8/2024, the three personnel records still did not have pediatrics/adult CPR certificates.

Correction Narrative: On 7/15/2024, the operation's executive director advised via safety plan, all staff CPR courses were reviewed. One staff has the required CPR. Three staff only have Adult CPR. Two staff have a card that says Basic Life Support (CPR and AED) in person program. Staff were asked to reach out to the instructor for clarification regarding the adult, child and infant training. Our plan of action is to have all staff complete the appropriate training as soon as possible.  We left a message to the provider to schedule a training.  We have two targeted dates, July 14 and July 21.


raw_content: During the initial inspection, one of the four personnel records reviewed, did not have a TB exam. During the follow up inspection completed on 7/8/2024, the personnel record still did not have a TB exam.

Standard Number / Description: 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


summary: 748.1339(a) - Initial Service Plan-Service planning team must develop the service plan

raw_content: During the follow up inspection, a child's service plan was reviewed for corrections from a previous deficiency, and at that time it was observed that the service plan was completed but it was developed without the service planning team's involvement. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.


summary: 748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent

raw_content: During the initial inspection, it was observed the child care administrator has been frequently absent and did not have a licensed child care administrator designated to be responsible for the operation in their absence. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

Correction Narrative: On 7/15/2024, the operation's executive director advised via safety plan, TVOH is aware that we are currently in need of providing an alternate Administrator to ensure we always meet the minimum standard. Our current Administrator will work a minimum of 3 days a week to meet the required hours.  The 3 days will be floating dates depending on the schedule and need. The administrator will complete a sign in sheet that will have the following: date worked, start time and end time.  The Administrator's schedule is floating dates and times to meet the required 30 hrs. total.  The Administrator will have a weekly overview of work done, i.e. files reviewed, correction action plans, and trainings administered.


raw_content: During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

Standard Number / Description: 748.303(e)(1)(B) - Serious Incident-Report to parents no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary


raw_content: During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

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

Correction Narrative: On 7/15/2024, the operation's executive director advised via safety plan, the current Administrator will work a minimum of 3 days a week to meet the required hours.  The 3 days will be floating dates depending on the schedule and need.  (note: The Administrator will have a separate schedule from the Executive Director). The current Administrator has been cleared to drive.  She has been and will stay in Tyler on the days she will work in Linden.  The administrator will complete a sign in sheet that will have the following: date worked, start time and end time.  The Administrator's schedule is floating dates and times to meet the required 30 hrs. total.  The Administrator will have a weekly overview of work done, i.e. files reviewed, correction action plans, and trainings administered.


summary: 748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules

raw_content: During the initial inspection, it was discovered the permit holder has failed to maintain compliance with Minimum Standards at all times. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

Correction Narrative: On 7/15/2024, the operation's executive director advised via safety plan, the permit holder and administrator discussed the obligation to respond to all requested deficiencies in the given time frame. Both ensured that all deficiencies will be addressed prior to or within the given correction date.


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

raw_content: During the initial inspection, it was discovered that 3 of the 6 children currently enrolled, were missing a 90 day follow up suicide screening as required in Minimum Standards. During the follow up inspection completed on 7/8/2024, the three child's records still did not have a 90 day follow up suicide screening.

Correction Narrative: On 7/15/2024, the operation's executive director advised via safety plan, TVOH will follow the Suicide Policy when conducting the initial suicide screening upon admission. TVOH is currently using Calibri Health for all behavioral therapeutic services. The initial suicide will be conducted by Calibri at the time of admission, after an incident, and the 90 day. If Calibri Health is not available to complete the above-mentioned, we will have the Treatment Director to assist. The Treatment Director is currently trained to complete the CSSR. TVOH will have upper management, Case Worker and DCS certified to complete the mentioned above by September 11, 2024. All staff will complete the required DFPS Suicide Training by July 13, 2024. This training is aligned with the requirements mentioned in our policy.


summary: 748.303(e)(1)(A) - Serious Incident-Report to Licensing no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary

raw_content: During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

Correction Narrative: On 7/19/2024, the operation's executive director advised TVOH will ensure to report required incidents to licensing as soon as we are made aware of allegations or indications of abuse, neglect, or exploitation of a child. TVOH hosted a virtual meeting to re-train all staff on serious incidents and reporting abuse and neglect.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed several bedrooms/bathrooms were not in good repair. Corrections were due on 6/10/2024. During the follow up inspection on 6/26/2024 and 7/8/2024, there were three bedrooms with chipped paint. The operation was re-cited for the deficiency.


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

raw_content: During the initial inspection, a caregiver was heard yelling at a child about taking clothes that didn't belong to the child. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.


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

raw_content: During a follow up inspection, it was found that there were still several issues with the exterior of the building. There was paint peeling off the building and siding was missing with insulation exposed. In the interior of the building the floors in the hallway and staff areas needed repair. There was paint peeling in 4 of the occupied rooms and 2 of the unoccupied rooms. Several of the screens had holes in them and needed repair. In two of the occupied rooms the drywall had cracks.


summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: The operation's administrator and permit holder have failed to provide adequate oversight of all operation staff and supervise their job duties appropriately as they are not present at the operation full-time or available immediately to assist in an emergency situation or intervene when an incident occurs at the operation.

Correction Narrative: The operation was notified of HHSC's intent to deny a permit on 8/5/2024, and as of this date, the operation has not requested an administrative review. The operation has no children in care and is no longer allowed to operate. A follow up inspection was conducted at the operation on 8/14/2024. The operation appears to be closed, and there does not appear to be any staff or children present at the operation. The permit holder was contacted via phone call during the inspection. The permit holder confirmed that all children have been discharged, and there are no staff working at the operation. The permit holder was not able to meet licensing at the operation at the time of the inspection. The permit holder contacted two former operation staff to see if they could meet licensing at the operation. Neither staff was available. The permit holder was provided with instructions on how to mail the operation's permit to licensing.


raw_content: Operation staff failed to provide appropriate supervision for a 13-year-old child in care that was required to have line-of-sight supervision. The staff member allowed the child to play outside of the operation alone, unsupervised and also allowed the child to leave the operation without a staff member or an approved adult to supervise.

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


summary: 748.1349(a)(3) - Initial Service Plan-Give copy or summary of plan to child's caregivers

raw_content: When a child's service plan has been completed, the operation's management staff does not discuss service plan requirements with direct care staff.


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

raw_content: Between 7/3/2024 and 7/14/2024, five requests were made to obtain operation documents. The documents were not provided until 7/18/2024.


summary: 748.2301(a) - Disciplinary Measures-only a caregiver known to and knowledgeable of the child may discipline the child

raw_content: During the investigation it was learned that a non-staff member verbal threatened to physically discipline a child in care.

Correction Narrative: CEO sent email stating the following: This is a training issue. Upper Management was not made aware of this altercation until after the fact. Child Rights Will Be Reviewed on 7/31/2024.


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

raw_content: During the course of the investigation, it was determined that the operation failed to provide a safe environment. Staff members failed to intervene when a non-staff member engaged in a verbal altercation with a child in care.

Correction Narrative: CEO sent email with the following corrections: This is a training issue. Upper Management was not made aware of this altercation until after the fact. Child Rights Will Be Reviewed on 7/31/24 during training.


summary: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

raw_content: During the course of the investigation, it was determined that a non-staff member engaged in a verbal altercation and threatened a child in care.


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

raw_content: During the investigation, it was learned that a non-staff member was at the operation on several occasions and did not have a complete background check. This non-staff member had access to children in care.

Correction Narrative:
CEO sent email stating the following: All Staff is aware that anyone frequenting the facility or around the foster children must have a completed background check.  In this case the person in question is the spouse of a former employee.  The gentle man is a State Patrolman and drove his truck to deliver large items to the facility. We did ask him for a background check in which we did run.  He was advised he could not come to the We were unaware that he was coming to the property on a frequent basis.

Update:  All staff will receive training regarding background checks requirements to review the background check requirements and eligibility for staff, volunteers and frequent visitors. Training was held on 7/31/2024 for most staff.  The remaining staff will complete the training on 8/6/2024.  All training certificates will be placed in the employee file within 48 hours of training.  The initial background check submission for the non-staff member in questions is attached. The non-staff member was notified additional steps needed to be taken to be deemed eligible


raw_content: During the initial inspection, it was discovered that 3 of the 6 children currently enrolled, were missing a 90 day follow up suicide screening as required in Minimum Standards.

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


summary: 748.303(e)(1)(B) - Serious Incident-Report to parents no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary

raw_content: During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location.


raw_content: During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location.

Standard Number / Description: 748.303(e)(1)(A) - Serious Incident-Report to Licensing no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary


raw_content: During the initial inspection, it was observed the child care administrator has been frequently absent and did not have a licensed child care administrator designated to be responsible for the operation in their absence.

Standard Number / Description: 748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent


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

raw_content: During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her.


raw_content: During the initial inspection, it was discovered the permit holder has failed to maintain compliance with Minimum Standards at all times.

Standard Number / Description: 748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules