summary: 748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223

raw_content: One child in care's file that was placed on 01/08/2025 did not have a copy of medical documentation.


state: TX

facility_name: Tomorrows Future Incorporated LLC

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

raw_content: Photos and documentation show child in care had a rash but there is no documentation if or when child was taken to the doctor for medical attention

Category: Child Care

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: Administrator is making sure two staff members are the once conducting body checks when child in care first arrives and contacting child's case worker. If any illness, injury or pain the staff are directed to immediately take child to the doctors within 48 hours.


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

raw_content: Job description in a staff file is missing for a LCCA position and staff is direct care staff.

Category: Reports and Record Keeping

Standard Risk Level: Medium

Correction Narrative: Our operation has corrected the mislabeling of an employee's position title. To maintain compliance, we have implemented a checklist to ensure all required documents are accurately filed in staff records.


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: Operation has not validated peoples list.

Category: Individual Standards Evaluated

Correction Narrative: The operation has successfully validated all background checks and will continue to do so every three months to ensure that all active employees are compliant and that records are current for personnel actively working within the organization. The administrator will conduct a monthly audit to ensure the validation is completed as required. The administrator will also add a remainder to the organization calendar to ensure its completed.


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: Two staff files are missing the notarized affidavit documentation.

Correction Narrative: The organization ensures that personnel records are thoroughly completed, encompassing all legally required documentation and adhering to minimum standards. The operation created a checklist that will be checked by the administrator during a monthly audit.


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

raw_content: A child was injured during an altercation.

Correction Narrative:
Email response from CEO stating We have taken the time to complete all requested exercises related to staff and volunteer retraining. This includes the following:
	A 4-hour Crisis Prevention Intervention (CPI) refresher training for all staff and volunteers, with a specific emphasis on physical intervention.
	The completed CPI training sign-in sheet (attached).
	Training certificates for each participant, which include the employee's name, date of training, total training hours, trainer's name, and signature (attached).
	Signed acknowledgment forms from each participant confirming their understanding that CPI-approved physical restraints are to be used only as a last resort (attached).
-Attachments have been uploaded to Documents Library.

A follow-up inspection was conducted, there were no concerns, inspector reviewed documents.


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

raw_content: Dosages were missing for 4 medications on the child's medication logs.

Standard Risk Level: Medium High

Correction Narrative:
Email recieved from the operation:

All individual Medication Inventory Sheet Top headings including the dosages were completely filled out, dates, etc. were double checked for error. Administrator/Treatment Director/ CEO will manage these logs solely, train & supervise direct care until further notice.


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

raw_content: Operation was using medication log with only the child in cares name and the rest of the form was left blank.

Correction Narrative:
All individual Medication Inventory Sheet Top headings were completely filled out, dates, etc we're double
checked for error. Administrator/Treatment Director/ CEO
will manage these logs solely, train & supervise direct care until further notice.


summary: 748.111 - Child-care policy required

raw_content: The policy did not mention child's right to mail, visitations, gifts and topics that are required.

Standard Number / Description: 748.111 - Child-care policy required

Category: Organization and Administration

Correction Narrative:
Administrator had revied child care policy has and has mentioned child's right to mail, visitation,
gifts and other topics that are required. The administrator will ensure all policies are adopted and signed once approved by licensing representative.


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

raw_content: Policy does not mention required annual training, methods to increase employee awareness, strategies and actions to prevent abuse and neglect of children.

Correction Narrative: Operation has updated the Abuse and neglect policy with revisions to mention annual trainings per minimum standards. Administrator will ensure all policies are signed and adopted once approved.


summary: 748.109 - Admission policies must include description of each program you offer

raw_content: While reviewing the policy the following descriptions were missing, ages of acceptance and type of programs the operation offers.

Correction Narrative: Administrator has revised and made corrections to admission policy meeting the minimum requirements. The administrator will adopt and get the policy signed once approved by licensing representative.


summary: 748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand

raw_content: While reviewing the policy the statement regarding during orientation the emergency behavior intervention will be explain in a manner the child can understand was missing. Examples different languages or pictures.

Correction Narrative: The administrator has revised the EBI policy to meet minimum standards requirements. The administrator will ensure all policies are adopted and signed by the CEO once they are approved by licensing representatives.


facility_name: Zachary's House LLC

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

raw_content: Food items were observed to not be properly stored. Multiple food items were out of the orignal package with no expiration date.

Corrected at Inspection: Yes


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

Correction Narrative:
A staff without a drivers license has been transporting children.

Effective immediately, the Director verifies that all staff assigned to transport children have a current, valid driver's license appropriate for the vehicle used prior to transporting any child. Copies of licenses are maintained in personnel files. License expiration dates are tracked, and drivers are not permitted to transport children if documentation is not current. Ongoing monitoring will be conducted to ensure compliance. During the in person inspection RCCL verified all staff members that provide transportation had a valid and current driver license.


summary: 745.635(2) - AP Background check determination - If ineligible then you must immediately remove subject from operation and confirm to CBCU receipt of notice letter

raw_content: An individual with an inactive background has provided care to the children.

Correction Narrative:
Zachary's House Residential Treatment Center has immediately addressed the deficiency involving background check eligibility. Upon discovery, the individual with an inactive background check status was removed from all duties involving direct care or access to children. The operation has reinforced procedures requiring confirmation of active and eligible background check status prior to allowing any individual to provide care or supervision. The LCCA will ensure that all background check determinations are continuously monitored, promptly reviewed, and documented. Any individual identified as ineligible or inactive will be immediately removed from the operation, and confirmation of receipt of the notice will be provided to CBCU if needed. These measures ensure ongoing compliance with background check regulations and protect the safety of children served by Zachary's House.

A child was interviewed and there were no concerns with background checks. A staff was interviewed about their conditions, and there were no concerns. The staff in question has not been at the operation, and a new background check was submitted.


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

raw_content: Staff failed to provide a safe environment by placing a child to share a bedroom with another child who has behavioral issues.

Correction Narrative: An in-person inspection was completed at the facility. A walkthrough was completed of the children's bedroom. During the walkthrough it was confirmed all children bedroom arranged didn't pose safety concern. In addition, the administrator will review all room assignment to ensure compatibility and safety.


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

raw_content: Staff failed to follow child's service plan in regard to his supervision needs.

Correction Narrative: An in-person inspection was completed at the facility. During the walk through it was confirm children were being provided with visual and auditory supervision by staff within ratio. The child's supervision level was reviewed and corrected to match approved service plan.


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

Correction Narrative:
The administrator is not maintaining full time hours at the operation.

The executive director has set up a clock in/clock out schedule that meet the requirement for full time employees. The executive director will completed weekly schedule reviews to ensure the employees are completing their required hours. The system in place will notify if an employee has failed to clock in/clock out on time. The minimum standards were reviewed with the executive director for the requirements for Administrator. A copy of the minimum standards were provided to the operation.


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

Correction Narrative:
The treatment director is not maintaining full time hours at the operation.

The minimum standards were reviewed with the executive director for the requirements for a Treatment Director. A copy of the minimum standards were provided to the operation.  The executive director will completed weekly schedule reviews to ensure the employees are completing their required hours. The system in place will notify if an employee has failed to clock in/clock out on time


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

Correction Narrative:
Upon reviewing a staff file, the staffs Crisis Prevention Intervention certificate is expired.

All staff were retrained for Crisis Prevention Intervention. A copy of the certificates were provided for review. To ensure on going compliance the executive director has put calendar reminders one month prior to the training epxiration as a reminder to complete the training prior to expiration date.


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

raw_content: The fire drill was completed in 12 minutes.

Category: Safety and Emergency Practices


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

raw_content: Three out of six employee files reviewed were missing the EBI trainers signature and qualification on their training.

Category: Training and Professional Development

Standard Risk Level: Medium Low


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

raw_content: Medication log did not include the purpose for the medication.

Category: Medication


summary: 748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking

raw_content: Three out of six employee CPR/First Aid Training Certificate are expired.


raw_content: The operation has no treatment director.

Standard Number / Description: 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

Category: Personnel

Correction Narrative: Director is to ensure the treatment director is present and completing all job responsibilities. The treatment director is expected to be present one day in office as per their job description.


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 operation has not validated their background check list.


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

raw_content: During the walkthrough of the facility, 2 open bowls of noodles and one open box of KFC Chicken was observed in the fridge.

Correction Narrative: Operation sent its correction via email. In the correction, it stated that a member of the administration team or lead staff will be present on-site to provide licensing active records upon request.


summary: 748.151(4) - Operational responsibilities - Allow Licensing to inspect the operation during its hours of operation

raw_content: Upon my arrival at the facility today 12-9-24 at about 9:15am to conduct the 2nd initial inspection, no staff was seen at the facility. I contacted the owner by phone, and he told me that he will not be at the facility today but will be there tomorrow.

Correction Narrative: A member of the administration team or lead staff will be present on-site to provide licensing active records upon request.


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

raw_content: Serious incident report doesn't include the name of the two children in care that were present at the home during the incident.

Correction Narrative: The operation submitted the serious incident report with the names of the two witnesses present during the incident. Moving forward the administrative team will review incident reports for accuracy and completed monthly binder audits for compliance with minimum standard's.


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

raw_content: When reviewing employee file there were no documentation obtain that demonstrate the operation verified applicant employment history.

Correction Narrative: The employee involved in the investigation has been terminated. Members of the administrative staff have completed an audit on all employee files to ensure employer's verification was completed.


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

raw_content: Staff failed to demonstrate prudent judgment by taking one alcoholic drink prior to starting his shift and doubling his medication without his doctor's notice.

Correction Narrative: The operation has terminated employee involved in the investigation. As part of the correction's submitted the operation provided their employee handbook that clearly states working under the influence of alcohol and illegal drugs is not permitted and can result in immediate termination. The operation provided their employee agreement that clearly outlines the operations policy and procedures employees sign off on. The operation review's the employee handbook and employee agreement on a one-on-one sit down prior to staff having contact with the children. A team meeting was held to remind employees about the drug and alcohol policy.


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

raw_content: Staff member failed to provide appropriate supervision to three children in care when he left earlier than scheduled without notifying management or finding a replacement resulting in a child running away.

Correction Narrative: Employee involved in the investigation has been terminated. Employees have completed a refresh supervision training. Supervision needs on the service plan for the children will be discussed in each monthly meeting. Both CEO and Designee are responsible for completing random night checks three times a month as well as daily check ins.


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

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

Correction Narrative: The employee involved in the investigation has been terminated. The operation has sent out the letter to notified parents of the deficiency. The operation employees have completed a refresh course of supervision training. Random daily check ins are completed to caregivers. Three random night checks will be completed per month.


raw_content: Child supervision needs on his service plan weren't being followed while he was on one on one.

Standard Number / Description: 748.685(c)(6) - Implement and follow the children's service plans.

Correction Narrative: The agency has requested an administrative review. The directors read the children's supervision needs and address those to the caregivers left in charge of the children. Caregivers will read children's service plan needs on a weekly basis to ensure they are being met.


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: Three children in care Children's Right Form were not signed.

Correction Narrative: The operation submitted a copy of the three Children's Right's signed. Executive director and LCCA will be responsible to review documentation before putting them in the children's binder to ensure compliance with minimum standards.


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

raw_content: During the walkthrough of the facility, cracked floor tiles was observed in the restroom, damaged cabinet in the restroom and inside the children room.

Category: Physical Site

Correction Narrative: The operation provided me with photos of the repaired cracked tiles which was replaced and photos of the repaired cabinet.


facility_name: Residential Care at the Summit, LLC

raw_content: A caregiver transported a child to school on November 17, 2025 while the child was suspended from November 13-17. The child was not provided the required staff supervision.

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

Correction Narrative: The staff were retrained on updated operational procedures for when a child is suspended from school and attempting to return to school without permission.


facility_name: J's House

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

raw_content: During the inspection, we observed four of four employee files reviewed evidenced reference checks not completed by the employee's date of hire.

Correction Narrative: On 12/3/25, the operation provided a correction plan showing they have amended their hiring process to include a statement in their offer letter stating hire date will be contingent upon completion of these checks.  They have also updated the onboarding checklist to require these checks to be completed in the pre-hire phase.  This brings this standard into compliance.


raw_content: During the inspection, we observed four of four employee files reviewed evidenced employment verification not completed by the employee's date of hire.

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


facility_name: Belle Place Limited Liability Company

summary: 748.3273(3) - First Aid Kits-Each one must contain antiseptic solution or wipes

raw_content: Three First Aid Kits were reviewed and found items missing or items that should be secured that a child could have access to.

Correction Narrative: First aid kits were checked to ensure compliance with necessary component items.


summary: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: The facility was not able to verify previous employment had been contacted prior to hiring the person.

Correction Narrative: Employee files with missing assessments will be completed to bring all files up to compliance to show 5 year employment history check.


summary: 748.864(d) - Pre-Service Training-Document the completion of each training requirement in the appropriate personnel record.

raw_content: Training was not in the personel files and could not be provided for review.

Correction Narrative: All employment files will be updated to include all necessary components including the pre service training log and relevant certificates.


summary: 748.1271(3) - Emergency Admission Documentation-Include any allergies (food, medication, sting, skin allergies)

raw_content: When reviewing the child's binder, at the facility, it was discovered that the complete list of allergies was not listed on the child's binder.


raw_content: During an investigation at the facility, it was discovered through interviews with a staff member admitted to giving, a child in care, a peanut butter cup and the child has a known nut allergy.

Correction Narrative:
The facility responded: Belle Place conducted an All Staff Training / Meeting, which was held August 7, 2025, addressing the intake concerns, documentation, medication logs, and room searches. A review will be conducted weekly, ensuring staff remains knowledgeable on any conditions or / allergies with each client.
In addition, Belle Place has implemented a Mandatory Town Hall Meeting, which will be held every 3rd Thursday of every month, made effective August 11, 2025.
Belle Place will continue to ensure that all intake documentation is reviewed by the Case Manager, as well as the staff being educated regarding notated allergies for each client.


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

raw_content: A caregiver was observed making negative comment about a child's eating habits. The child has a documented history of struggles with weight, which have previously contributed to suicidal ideation and hospitalization.

Correction Narrative:
Received corrective action plan from the administrator stating: Belle Place Staff received a review regarding Child Rights during a virtual meeting on July 17, 2025In addition to receiving materials for review under the guidelines of Minium Standards Texas on July 17, 2025. Belle Place will provide Monthly Training Refreshers that address the importance of providing a supportive, appropriate and safe environment.
Standard/


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

raw_content: The counts for four of the childs prescribed psychotropic medications did not match the documentation in the records on multiple days.

Correction Narrative:
Received corrective action from administrator stating: Medication Audit Sheet made effective July 22, 2025. Weekly medication audits will be conducted on the clients placed in care at Belle Place. In addition, staff were provided with a refresher notification on the importance of using the following forms:
1)
Medication Discard Form
2)
Medication Label Error Form
3)
Medication Error Form


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

raw_content: According to statements from two caregivers, the child in care discarded her PM medications on the night of the incident and retained three pills of her prescribed bedtime medication to use at a later time.  The child was not given a replacement dose for the discarded medications, nor did the caregiver retrieve and re-administer the retained pills.

Correction Narrative: Received corrective action plan from the administrator stating: Belle Place Staff received two (2) additional Medication Trainings as follows: 1. DFPS Online Medication Training (review, with certificate) ...due by July 2, 2025. 2. In-person Mandatory Medication Training scheduled for July 8, 2025, conducted by a Nurse Practitioner.


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

raw_content: Two out of two files are missing signed and dated documentation.

Correction Narrative: All staff files have been updated to include signed and dated statements by the employee(s) that each must immediately report suspected child abuse, neglect or exploitation.  A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


summary: 748.915(a) - Document the caregivers completion of each training with cert or letter of completion in the appropriate FH or personnel record

raw_content: Two out of two staff files did not have completed required training.

Correction Narrative: Staff files have been updated to reflect completion of each training.  Staff members whose file(s) are lacking info will be removed from work rotation until training(s) have been completed. A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


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

raw_content: Two out of two staff files are missing signed documentation.

Correction Narrative: All staff files have been updated to include signed and dated statements by the employee(s) that each has read a copy of the operational policies. A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


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

raw_content: Two of two staff files are missing notarized documentation.

Correction Narrative: Reference verification was completed for each employee to ensure their suitability to work with or around children.  A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


raw_content: Two out of two staff files have not completed reference checks and missing documentation.

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

Correction Narrative: Reference verification was completed for each employee to ensure their suitability to work with or around children. A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


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

raw_content: Two out of two staff files are missing signed and dated documentation.

Correction Narrative: All staff files have been updated to reflect completed Pre-Employment Affidavit for Applicants for Employment. A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


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

raw_content: Two out of two staff files were missing any education transcripts.

Correction Narrative: 748.681(2) Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentation of equivalency from home schooling. Two out of two staff files were missing any school transcripts. All staff files have been updated to reflect proper educational qualifications	Completed 2/17/2025 A checklist was created to ensure all required documents are presented in the staff file. The administrator will conduct monthly audits to ensure all required documents are presented in the file.


facility_name: NEW LIFE RESIDENTIAL TREATMENT CENTER

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: During the review of staff files the file was missing reference checks whom are unrelated to the staff.

Correction Narrative: The administrator emailed me the employee references checks and it was approved to meet compliance for minimum standards.


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

raw_content: Multiple food items were observed to not be properly stored as they were open. Multiple food items did not have the expiration date written on the package.


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: In reviewing 1 of 2 charts, it was found one of the children had a history of sexually abusing other children, but a Safety Plan was not put into place.

Category: Admission, Service Planning, Discharge

Correction Narrative: An unannounced follow up inspection was conducted on 2/25/2026. A full walkthrough of the facility was conducted and no concerns were observed. Staff were interviewed regarding safety planning and reported if a child in care has high-risk behaviors, a safety plan will be immediately implemented to ensure their safety. The administrator reported safety plans are also done after a child is discharged from behavioral hospital. The safety plan for the child in care was obtained and reviewed. No concerns were observed with the safety plan received.


summary: 748.125(c)(1)(C) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of suicide screening.

raw_content: The LCCA confirmed that the staff have not completed the suicide training via email.

Correction Narrative: received email from the LCCA confirming that staff have completed suicide training.


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

raw_content: The victim's service plan states that he must attend substance abuse counseling once a week. The administrative assistant confirmed that the victim has not been scheduled to go to substance abuse counseling and has not attended a session. Based on the information reviewed, there is a preponderance of evidence that New Life RTC has not been following the service plan.

Correction Narrative:
An email was received on 12/05/2025 at 1:57pm from the administrator regarding a corrective action plan to ensure that the service plan of children in care is implemented and followed timely:

Preventative Measure(s):

To support the well-being and adjustment of all newly arrived children, New Life RTC will ensure that every child is signed up for therapy as soon as possible after their arrival.

Action Steps
1. Complete the therapy enrollment forms for each child within the first 48 hours of arrival.

2. Coordinate with the therapy provider to schedule the child's initial assessment and first session within the first week.

3. Document the enrollment and appointment dates in the child's file for future reference and follow-up.

4. Ensure the treatment plan is followed as stated.

By taking these steps, we ensure that all children receive the mental health support they need, building a foundation for their successful integration and well-being.


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

raw_content: The unauthorized absence log is missing the eloped child's age, gender, date of admission, caregiver responsible and information on if law enforcement was contacted.

Correction Narrative: An email was received from LCCA with an updated Unauthorized Absence Log on 12/28/25. This updated log will be used moving forward and will replace the previous log that was non-compliant. The updated log will include the child's name, age, gender, DOB, DOA, time and date of UA, caregiver responsible, hotline intake #, and LE information.


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

raw_content: One staff file was missing required documentation.

Correction Narrative: The operation created a checklist to ensure all required documentation will be provided. The staff will conduct a monthly audit to ensure all required documentation is presented.


summary: 748.949(a) - Annual Training Documentation-Keep documentation verifying completion of training in the personnel record

raw_content: One staff members file did not have required documents.


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 file evaluated did not have required documentation.


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

raw_content: Two out of two first aid kits were missing required items.

Correction Narrative: The operation purchased items missing on first aid kit. The staff will conduct a weekly audit to ensure all required items in the operations kits.


facility_name: ACH Child and Family Services

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

raw_content: During the time of review, it was discovered that staff used inappropriate language when talking to children in care while on an outing.

Correction Narrative: Operation came into compliance by terminating the staff


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

raw_content: During the time of review, it was discovered that the caregiver fell asleep while on duty supervising children in care while on shift.

Correction Narrative: The operation came into compliance


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

raw_content: Two serious incident reports did not document witnesses of the incident.

Correction Narrative: Compliance was met when the operation provided witnesses initials on the SIR's. Operation also will have staff list every client in the home as a potential witness.


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

raw_content: During the course of this investigation when reviewing documents, it was stated by caregiver and residents that the caregiver used inappropriate language around children in care.

Correction Narrative: The operation came into compliance by conducting a meeting on 7/30/2025 regarding profane language and prudent parent standard and provided meeting notes with all staff signatures.


summary: 748.303(a)(4)(A) - Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child

raw_content:
Two children went from a verbal altercation to a physical altercation. One child
required a hospital visit. There was no reported called in to Licensing.

Correction Narrative:
The operation came into compliance by having a meeting with the team that covers IRs and being on call covered reasons for calling in incidents, looking at specific standards, and how they should be documented in the Incident Reports. the operation also required staff to take trainings that address different areas of building connections with clients and managing the milieu and building
positive culture amongst staff and clients. The operation also requires all staff on the Wedgwood Campus to take 3 trainings for EBI Refresher.


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

raw_content: At the time of inspection, there were no visible policies regarding the BARK app. The electronic rules and agreement did not reference the installation of the BARK app on the electronic devices of children in care. Additionally, the children's services plans did not stipulate the requirement for the BARK app to be installed on all such devices. The electronic rules and agreement were brought in compliance after the investigation intake on 4/23/2024 when the agreement form was updated.

Correction Narrative: The operation came into compliance by submitting signed Electronic Rules and Agreement forms signed by all children in care.


raw_content: A caregiver who was responsible for caring for children fell asleep while they were on duty and caring for children in care.

Correction Narrative: Operation immediately terminated the caregiver ad stated that We are thoroughly training the staff and are really emphasizing, to the wake at night staff, that falling asleep on the job is failing to meet the needs of the clients and is an immediately terminable offense. The staff in this incident was terminated for cause. We are also increasing the frequency of checks from the overnight shift supervisor. The Wedgwood campus has increased the auditing of video by the program supervisors to make sure children are being supervised. This employee was operating outside of the trained parameters and expectations of the job. The checks and balances put in place at the agency caught the issue and allowed us to remedy the situation and part ways with the employee.


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

raw_content: A youth care specialist who was standing next to two children in care, failed to intervene when the two children in care got into a physical altercation. Another youth care specialist that was several yards away had to run over and intervene and a third youth care specialist also had to run over to help. While the youth care specialist that was next to the two children stood back and did not intervene or assist the other two youth care specialists.

Correction Narrative: To ensure compliance with the above-mentioned standard, a corrective action plan will be written for the mentioned youth care specialist (YCS), following disciplinary action. Staff will be retrained on when and how to intervene during client conflicts to ensure client safety. Staff will utilize shift huddles, daily emails and the shift change check sheets to communicate concerning behaviors and client safety at the beginning and end of every shift. Staff will be able to seek support and guidance from ACH on-call for immediate concerns.


raw_content: A Youth Care supervisor did not perform a body scan on a  high risk child who was known to self-harm after blood was found in the childs  bathroom.

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

Correction Narrative: To ensure compliance with the above-mentioned standard, a corrective action plan will be written for the youth care supervisor (YCS). The YSC will be retrained on the ACH suicide prevention policy and re-reread  and acknowledge safety plans for all Behavioral Care clients. Staff will utilize shift huddles, daily emails and the shift change check sheets to communicate concerning behaviors among clients. Staff will be able to seek support and guidance from ACH on-call for immediate concerns


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

raw_content: One of the two child files reviewed showed that the child's prescription medication was not picked up from the pharmacy timely and the child missed their dosage.

Correction Narrative: To ensure compliance with the above-mentioned standard and ensure that medication is picked up timely and distributed as prescribed going forward, the ACH nurse will conduct weekly audits by reviewing the electronic medical record to notate distribution of medications as prescribed. An assigned Wedgewood staff will complete weekly audits to notate medication counts and refills needed. Once a medication hits 14 pills, the Case Manager/Treatment Director will need to be notified. This will ensure that the case manager has enough time to reach out to the providers to request a refill, schedule or adjust appointments, and ensure that medications are delivered on time through Pharmerica Pharmacy. Staff will inform the Case Manager/Treatment Director and document through their shift daily emails and medication management TEAMS channels the expiring medication and medication count until a new prescription is delivered. The medication had already been picked up on the day of the monitoring inspection.


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

raw_content: One of the two child files did not have the medication records from December, January, or February. The operation switched to digital files at the end of February.

Standard Risk Level: Low

Correction Narrative: The operation switched to digital files in February 2023 and are in the process of scanning all documents into the system.


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

raw_content: Incident reports do not include the physical address or the telephone number.

Correction Narrative: Operation director emailed me a copy of the updated incident report. The report now includes a place to document the address and the telephone number.


summary: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

raw_content: A child was not taken promptly to receive medical care.

Correction Narrative: A follow up inspection was conducted at the operation (Inspection #3894687). Operation treatment director was interviewed regarding the plan for ensuring medical treatment is obtained timely. The operation will talk to children involved in the incident to determine if they need medical attention. If the child is in need of medical attention for an injury or illness the operation will immediately take the child to their PCP, Urgent Care or if it is after hours or the operation is unable to get to the child into the doctor's office they will take them to Cook's Children Emergency Room.


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

raw_content: A child with a history of high risk behaviors for sexually acting out was not adequately supervised by staff.

Correction Narrative: Operation administrator emailed the safety plan that was implemented on 6/24/2021. The plan includes several requirements such as closer supervision, education on inappropriate contact/boundaries, outings, and reporting/documentation. The staff member involved in this investigation no longer works at the operation.


facility_name: The Childrens Home of Lubbock

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

raw_content: Medication logs reviewed had missing dates for when the prescription was administion.


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

raw_content: Medication labeled to be administered for the afternoon and evening were dispensed in the morning. The medication was stored unsecured in small cups that were not labeled. The medication logs were pre-filled prior to medications being administered to the child is was prescribed to.

Correction Narrative: 4079109. Per email from Unit Director, the operation revised their medication administration procedures and provided training to all house parents and staff. A copy of the email will be uploaded into the document library. An inspection on 10/3/25 reviewed medication logs with no concern. The Unit Director advised each house parent was retrained and each cottage was provided a guide with instructions for administration of medication.


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

raw_content: A child in care received medication prescribed to another child and the error was not documented.


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

raw_content: A caregiver used yelling, demeaning remarks and abrasive tone towards children in care.


raw_content: A house parent's disparaging comments and looks make a child in care feel excluded and isolated from the others residing in the cottage.

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

Correction Narrative: A follow-up inspection was conducted at the facility on January 27, 2025. During the inspection, the inspector met with the administrator and vice president, who relayed that the caregiver in question had been placed on a safety plan. As part of the plan, the caregiver is required to meet with her supervisor weekly for progress updates, among additional requirements. The vice president noted that the caregiver is showing improvement, and no further issues have been reported. It was mentioned that the safety plan will continue for as long as deemed necessary by the facility. The vice president also relayed to the inspector that the case managers will frequently be checking in on the children in the cottage to ensure any issues are promptly addressed.


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: A child record was missing a signed and dated child's rights form.

Category: Children's Rights

Correction Narrative: During the exit interview, the case manager received the child's rights form from the child's permanency worker. The case manager printed a copy to place in the child's record.


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

raw_content: 5 of 5 preliminary service plan did not have a date when it was completed.

Correction Narrative: A date and time box was added to the 72 Hour Plan of Service and Admissions Assessment.  In addition, GRO Admission staff and Casemanagers were directed to complete the documents on or before the admission date.


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

raw_content: Children's records were no documented accurately and were contradicting.

Correction Narrative: Operation completed a Case managers and Unit Directors meeting dated 2/28/24 to be sure that all documents especially Intake Assessments and Initial 72 Hour Plans of Service are true and accurate. They case managers were informed of concerns found during monitoring. The case managers will double check their work to ensure there is no contract icing information.


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: Medication records were not documented cumulative to show if the child was administers his PRN medication.

Correction Narrative: Follow up completed with verification of records. Operation conducted meeting/training with house parents and case managers 08/24/2023 detailing what is required to be in a medication log and providing understanding how running medical records should be. House parents were taught their specific task and how the first part of a running medical record begins in the cottage. Operation has reached out to Pharmerica to ensure that they are including required documentation with medications so that we can have all med logs up to date with possible side effects and contraindications.


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

raw_content: The operation failed to provide a child in care medical care when he exhibits signs of ringworm.

Correction Narrative: The Child reveived medical care.


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

raw_content: Multiple incident reports reviewed did not include a clear resolution to incidents involving concerns for infant care, supervision, medication, and unauthorized absences.

Correction Narrative: Staff and Caregiver will be provided additional training.


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: Multiple incident reports reviewed did not specify what (if any) interventions were made to reduce risk to children involved in the incident.


raw_content: Medication logs did not document  the reason, date,  time or the phone call to the pharmasist upon discovering the medication error.

Standard Number / Description: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs


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

raw_content: Four of four child records reviewed did not include details in the transfer summaries for the circumstances of the transfer or the date the child was informed of the transfer.

Correction Narrative: Transfer/Discharge paperwork has been updated to identified the requirements in 748.1437.


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

raw_content: A child in care was placed on punishment for 2 months.

Correction Narrative: On June 6, 2023, RCCR Inspector conducted an unannounced inspection at the Children's Home of Lubbock located at 4404 Idalou Rd Lubbock, Tx. A walkthrough of the cottage was conducted, and there were no concerns. At the time of this inspection, the Unit Director provided a termination letter stating that the alleged perpetrator was terminated from his position at Children's Home of Lubbock effective date June 2, 2023, and cottage 5 is closed temporarily. The operational director states during a meeting, the staff was reminded of the rules and regulations for approved discipline at the operation. The termination letter is uploaded into Sharepoint.


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

raw_content: Six of six fire drills reviewed did not include appropriate documentation to reflect the evacuation was completed within 3 minutes.

Correction Narrative: Operation created a new form that included all areas required by standards. On 3/29/2023 Operation conducted a staff meeting with all house parents and discussed the importance of fire drills and the documentation needed. In person follow up will be completed in April 2023.


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: Severe weather drill werer not completed every six months.

Correction Narrative: Operation discussed with operation the importance's of severe weather drills.  On 3/9/2023 Operation conducted a staff meeting with all house parents and cottage supervisors informing them the requirement and time frames.  In person follow up will be completed in April 2023.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operational administrator failed to schedule a continuous and 24-hour staffing pattern that affected the supervision of 6 children in care.

Correction Narrative: The operation has created a new process to ensure that a second person (which will be an additional administrator) that is required to review all direct care staff's schedules. This information was reviewed during the inspection to verify each administrator checked the applicable weekly schedule and that it met all ratio and supervision requirements.


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

raw_content: An overnight caregiver left the facility after completing her scheduled shift leaving six children unattended and unsupervised.

Correction Narrative: The operation has created a new process regarding campus supervision and staff transitioning. Unit Directors will have team meetings with the overnight staff to ensure there is not issues regarding scheduling or concerns such as other staff arriving late, no showing up or not completing their documentation accordingly. The operation has developed a transition form in which they turn in to the main house parents and overnight staff. All staff are to make visual contact with the staff relieving prior to leaving the cottage and the children.  If there is no relief staff then on-call will be contacted.  This information was reviewed during the inspection to verify that each administrator checked the applicable weekly schedule and that it met all ratio and supervision requirements. The operational new process was found to be compliant at this time.


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

raw_content: One of the cottages was observed to have bed bugs and extended amount of bed bug feces on the furniture.

Correction Narrative: Follow up was completed on 12/29/2022 by inspection. The operation The residents are still in cottage 7 but will be returning to their cottage this week. The operation received their quarterly pest control services, serviced on August 2022 for the entire campus, upon becoming aware of the infestation in Cottage 5 the Cottage received three bed bug treatments.  The dates of the bed bug treatments were November 12, 2022, November 18, 2022, and December 1, 2022.  The cottage has replaced the furniture in cottage 5 due to bed bugs. As per Case Manager the operation is doing a weekly walkthrough of the homes to ensure there is no concerns regarding pest or cleanliness. Additionally caregivers report that they are more mindful of the signs for bed bug infestation and feel confident in understanding the early signs of an infestation. Main house parents are conducting a walkthrough of then home weekly ensuring there is no signs of any unsanitary living.


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

raw_content: A 32-year-old volunteer for the operation engaged in inappropriate sexualized contact with two 10-year-old males in care.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operations has terminated the Child Mentoring Program.   They will also be conducting a training with all staff on reporting serious incidents.   A refresher course will be provided for all overnight staff, direct care staff, case managers and directors regarding reportable incidents and time frames. Form 7266 was emailed to the case managers/ parents informing them of citation 749.1003(b)(1)(B).


summary: 748.535(3)(E) - Child-care administrator responsibilities-Administering and managing the operation according to your policies.

raw_content: The administrator failed to ensure compliance with the policies and procedures that are related to volunteers, contracted, and subcontracted individuals which caused harm to child in care.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If in the future the operation chooses to begin the program again Administrator over individual programs such as the mentoring program will ensure that all standards are being met in the future.   They will review pertaining standards, incorporate the standards in their policy, provide RC with updated policy and procedures to ensure that standards are met or exceeded.


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

raw_content: The operational staff were notified of an abuse allegation and did not properly report the allegations of abuse within the required time frame as noted in Minimum Standards.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation is re-training all staff in reporting abuse and neglect, including live-in, overnight and direct care as well as Case managers and directors.


summary: 748.119(2) - Volunteer policy - Address qualifications, screening, and selection procedures for the volunteers

raw_content: The operation's volunteer policy does not document job descriptions, and/or responsibilities for the volunteers, qualifications, screening, selection procedures, orientation training programs, or the documentation of the contact with children.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again operation will ensure volunteers are not missing the required documents.


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

raw_content: The operation did not have appropriate documents in the volunteer's file as required in their operational policy. The operational volunteer file did not have the sponsor packet information, sponsor orientation, and training.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again the operation will ensure policies and procedures are not only discussed with the individual but documented accordingly in the file of each individual.


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

raw_content: During the course of the investigation, it was determined that an operational volunteer did not use proper judgement and did not demonstrate self-control in the presence of the children by engaging in inappropriate sexualized contact and behavior with two children in care.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The person involved was a volunteer at the operation and was immediately stopped from further contact with children.


summary: 748.725(b)(2) - Must get written approval from the parent for a volunteer or a volunteers family to take a child in care for a visit.

raw_content: The operation did not obtain prior written approval and consent from a child in care's managing conservator prior to the child being permitted to leave the operation with a volunteer.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again operation will ensure written approval is obtained and placed in the child file.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: A volunteer at the operation did not have a TB screening in his operational record.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again operation will ensure volunteers have appropriate screening.


summary: 748.729(3) - Day or overnight visit - prior to visit receive same information as required for respite care as specified in 748.4265

raw_content:
The operation did not give a volunteer required information such as emergency contact information prior.
 to allowing the child to complete visitation with the volunteer.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again operation will ensure volunteers are provided with the appropriate information requested per minimal standard 748.4265.


summary: 748.723(b) - Volunteers and Contractors-Personnel record documents how volunteer requirements are met if person performs an employee function

raw_content: The operation did not have written documentation on how the volunteer met the requirement to performed employee functions.

Correction Narrative: Inspection/Assessment ID #3931274 confirms the in person follow up. The operation has discontinued the volunteer/mentor program. If program is implemented again operation will ensure volunteer record document how they meet the requirement to perform employee functions.


summary: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.

raw_content: Caregivers are using demeaning language while speaking to the children in care.

Correction Narrative:
The operation is in compliance with the citation. The employee involved in the allegations was placed on administrative Leave on 9/24/2022. The caregiver is currently involved in investigaytion #2937216 . The operation will make their final decission if to terminate the employee or  provide her with additional training to return to work.  The operation is in compliance with the citation. The employee involved in the allegations was placed on administrative Leave on 9/24/2022. The caregiver is currently involved in investigation #2937216 . The operation will make their final decision if to terminate the employee or  provide her with additional training to return to work.  The operation reviewed their discipline policy with all current caregivers in their monthly meetings which included children's rights regarding caregivers using demeaning language.

UPDATE: the staff was ultimately terminated in December 2022 per termination paperwork provided by the operation.


summary: 748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication

raw_content: A caregiver allowed third party to administer medication without proper training.

Correction Narrative: A telephone call with the administrator confirmed that the caregiver involved in this investigation is no longer employed by the operation.  A follow-up e-mail was received on this date that confirmed that the unit directors will review and remind all staff in the next GRO campus training on 9/15/2022 about the minimum standard/licensing requirements when administering medications.


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

raw_content: Caregiver struck a 14 year old child with a shoe.


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

raw_content: Child in care was subjected to inappropriate punishment in a form of yelling.

Correction Narrative: The worker was terminated and no longer present the operation. The worker is not eligible for rehire.


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

raw_content: One out of four active childrens records did not include a preliminary serviec plan.

Correction Narrative: The operation completed the Preliminary Service Plan.


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

raw_content: Per 748.1215(a) a completed and signed admission assessment must be in the childs record prior to admission. One out of four active records did not have admission assessment.

Correction Narrative: Admission Assessment has been completed by the operation. The Operation has signed and filed the assessment, a copy has been placed in the  on Childs records.


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

raw_content: A matttress cover was not intact and exposed the internal composition of the mattress.

Correction Narrative: The operation ensure the child's bed was made with appropriate bedding and a mattress cover.


summary: 748.1101(b)(1)(C) - Children's rights-Adhere to the child's right to receive fair treatment

raw_content: A caregiver treated some children in care more favorably than newly placed children in care.

Correction Narrative:
Inspection 3824809

During an inspection of Cottage 6 on May 14, 2021 no obvious health or safety concerns were noted.  The staff identified in the investigation was not observed working in the cottage.  Additionally, the Administrator provided termination paperwork for the staff and indicated the operation will incorporate a review of child rights into the quarterly discipline training required by its Heightened Monitoring Plan.  The Administrator verbally waived due process.


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

raw_content: A caregiver has used racial slurs and inappropriate humor in the course of conversation with children in care.


facility_name: Boles Childrens Home Inc

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

raw_content: Staff does not have Normalcy training.

Deficiency Narrative: Staff does not have Normalcy training.


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content: Front windshield of the van has a crack across its surface. The rear view camera is inoperable.

Category: Transportation


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

raw_content: During the walk through of the homes, one home had broken blinds and one home had a broken shower door and knicks/missing paint on bedroom walls.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: Discontinued medication was found in a caregiver's home.


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

raw_content: During the walk through of the homes, one home was found to have multiple medications, including over the counter that was also not locked up and accessible to children.


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

raw_content: A child's initial service plan was not completed within 45 days.


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: Of the three child files reviewed, all three did not contain a 15 day notice to the parents for the service plan meeting.


facility_name: High Plains Children's Home

summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: A caregiver did not follow a child's service plan by allowing a child to participate in a supervised visitation without confirming supervision.

Correction Narrative: On December 19, 2025 an email was received from the Director stating that on December 3, 2025 all staff were talked to about not leaving children unattended for visitation and handing children off to St. Francis staff. The house parents involved in this incident have resigned and will no longer be employed after 12/21/2025.


summary: 748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model

raw_content: The operation failed to document medication administration on multiple occasions.

Correction Narrative: The operation has spoken to the staff on duty on missed the documentation and he was retrained on 9/9/25. Operation Case manager will be checking medication logs weekly, to ensure medication is being given correctly and documented correctly.


raw_content: A caregiver made shaming and ridiculing comments to a child in care.

Correction Narrative: An email received from the Director of Operation stated that the staff member involved in the incident has been released from her position at High Plains Children's Home.  The operation will continue to ensure that all staff members are aware of discipline that is approved by the operation.


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

raw_content: The operation did not complete daily notes for two children in care as per their policy.

Correction Narrative: Since the issued citation the operation has updated their policy. Previous policy stated they would document daily notes for children admitted, this requirement is an operation policy only since the citation the operation has decided to remove this policy from their manual.


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

raw_content: The operation failed to provide appropriate supervision for children in care after learning of an older male youth having inappropriate feelings for a younger child in care.

Correction Narrative:
An inspection was completed at the operation.  Interviews with direct care staff stated that they had been in on discussions regarding when safety plans are needed for children at the operation.

The administrator stated that in the future they will ensure a safety plan is put in the place regarding any situations when increased supervision is needed and will ensure that all direct care staff are aware of the safety plan requirements.


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

raw_content: One cottage program has not had a fire drill since 5/16/2023.

Correction Narrative: An email was received from the compliance specialist which contained a fire and tornado drill that were completed on 1/30/24.  The operation compliance specialist stated that she will ensure that calendar reminders are which alert each cottage when fire and weather drills are needing to be completed.


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

raw_content: One child record out of eight did not have a preliminary service plan completed within 72 hours.

Correction Narrative: An email from the compliance specialist stated that she has spoke with the case management staff regarding the importance of the Preliminary Service plan being completed within the required time frames. She stated that the Extended Reach system will send a notification if the plan is not completed in a timely manner.


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

raw_content: A caregiver used profane language and children in care were subject to this profane language.

Correction Narrative: Administrator called and the house parents have received additional direction. Administrative staff always have on call staff 24/7 to help in any situation.


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

raw_content: Two caregivers engaged in verbal argumentative conversation, and one caregiver threw an object when children were present.

Correction Narrative: The administrator informed that the house parents resigned, and all staff know they have administrative support 24/7. This incident was isolated due to the house parents' personal stress.


summary: 748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care

raw_content: Caregivers failed to keep medical discussions private.

Correction Narrative: Administrator emailed stating all direct care staff have been reminded about confidentiality of all children in care. Direct care staff were informed of what all is confidential.


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

raw_content: The overnight staff was discovered asleep while on duty.

Correction Narrative: 6.26.23Received an email from compliance director the staff on duty did not return and was released from the operation. 6.29.23 Face to face meeting at facility.


raw_content: Staff did not follow operational procedures when they were on duty.

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

Correction Narrative: 6.26.23Received an email from the director of compliance. All staff have been retrained and the employee was released. 6.29.23 meeting at facility.


summary: 748.2307(14) - Other Prohibited Punishments-withholding food that meets the child's nutritional requirements

raw_content: Caregiver did not allow the children to finish their dinner due to misbehaving.

Correction Narrative: A follow up inspection was conducted at the operation interviewed with caregivers, whom reported they were made to review discipline policy.


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

raw_content: Three bathrooms in the emergency shelter had shower mold  that needed to be removed.

Correction Narrative: Administrator called and said all painting has been completed. The shelter is ready for inspection. Inspection completed on 3/27/23


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

raw_content: A caregiver failed to provide the appropriate level of supervision necessary when two children in care were allowed to continue to share a bedroom, after they engaged in inappropriate behaviors together and when the operation was aware of concerns for possible sexual acting out behaviors with one of the children.  As a result, the children continued to engage in inappropriate behaviors.

Correction Narrative: Ms. Moody stated that they would tell staff exactly what increase in supervision is and that the children will be separate after the first incident to prevent further incidents from occurring. A discussion with licensing about the best way to handle this situation was also had.


raw_content: A child was sick and had to wake the overnight staff to get medical care.

Correction Narrative: Phone call with administrator staff has received one on one additional training on reporting. Regular training for all staff overnight will be conducted. The staff that was on duty was terminated 7/24/22.


summary: 748.125(b) - All employees and caregivers must be aware of and follow your operation's policies and procedures

raw_content: Overnight staff and day staff were not following the operation's policies; operation will have 24 hour awake staff. Staff was asleep while on duty.

Correction Narrative: Phone call for administrator informing that staff have received trainings about following policies in reporting, and awake staff and their responsibilities.


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

raw_content: Staff did not comply with the operations policy of having evening staff check on the kids 3-4x during the night at different times.


summary: 748.1217(b)(3) - Admission Assessment-At admission, must include description of child's behavior, appropriate & maladaptive, behavior posing risk to self/others

raw_content: Out of three child files reviewed one file did not have the admission assessment  completed within the required time frame.

Correction Narrative: Ms. Fletcher emailed stating they had conducted a retraining for case managers to ensure  Admission Assessments are completed as required by minimum standards. She also stated that they have also changed settings in extended reach to ensure there is more timely notification of when Admission assessments are due.


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

raw_content: A child in care did not recieve prescription medication for two days.

Correction Narrative: Received and email that the cottage house parents were retrained. Certificates received for the additional training.


summary: 748.1217(b)(10) - Admission Assessment-At admission, must include documentation of efforts to obtain required information, if any information is not obtainable

raw_content: While reviewing three child records it was noted that two of the three admission assessments were no emergency placement were not completed prior to admission.


raw_content: A caregiver did not demonstrate prudent judge when she engaged in sexual conversations with residents.

Correction Narrative: Email, phone call and inspection completed. Staff is no longer employed at the operation. Newly hired staff will received prudent judgment training and examples and will be implemented in those trainings.


raw_content: An alternative house parent failed to ensure a child had taken their medication. The child in care had eight prescription Zoloft in her possession when the primary house parent completed a search.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

Correction Narrative:
This citation was followed-up on during a Heightened Monitoring inspection (#3856347) at the operation on 12/22/2021 by Heightened Monitoring Supervisor Lindsey Franco.

Supervisor reviewed a training sign-in sheet dated 12/21/2021 where the Administrator trained the involved staff regarding medication administration.  The training included information regarding observing children taking their medications, checking for cheeked medications, and having the child sit in your presence for 30 minutes after taking medication.  It was also discussed that only one child should be present at a time when administering medications, watching the child to make sure they only use their fingertips when taking the medication, and not placing in in their hands to make it look like they've taken it.  It was discussed that the supervise should be contacted if there are any problems with medication administration.  Supervisor Franco spoke with the Director of Admissions and Compliance, who noted that if there is any issue with the child cheeking medication, it will be noted in the medication log, the child's daily notes, and will be immediately reported to the supervisor and case manager.  Supervisor Franco also reviewed all medication logs for the Owens and Christy Cottages, with no medication administration errors observed.  This citation will be marked as compliance met.


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

raw_content: A service plan indicated that supervision was required inside and outside of the home, but lacked any details regarding the level of supervision required.

Correction Narrative: The operation emailed stating all case managers have received information to ensure that all of the service plan is completed. This is to be reviewed by supervisors for final approval.


raw_content: A child's Preliminary Service Plan was not completed within 72-hours. The child was admitted on 8/23/2021 and the Preliminary Service Plan was completed on 8/31/2021.

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

Correction Narrative: The operation emailed stating they have made changes to their software to ensure that dates are not missed causing issues with non compliance. The software will notify case managers prior to regulated time frames to ensure all Preliminary service plans are in compliance.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: Video footage shows a caregiver uses an improper restraint when they twist the child's arm and place the arm behind the child's back.

Correction Narrative: The operation called and emailed their corrective action plan. Training on EBI was out sourced and staff received 4 hours on de escalation The Cost of Caring. The operation is writing new EBI policies that will not allow restraints. The staff involved in the restraints will only use de escalation technics and will not use any restraints on residents. Once the new Policies on EBI are completed the rep for the operation will received a copy.


summary: 748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint

raw_content: Caregivers did not follow a child's de-escalation method that was listed in the child's orientation admission record. The caregiver took away a radio as a form of discipline when the child's orientation records reflected the child listens to music for de-escalation.


summary: 748.2461(b)(2) - Short Personal Restraint-Caregiver may not use restraint that impairs child's breathing by putting pressure on torso

raw_content: Video footage from the operation shows a caregiver leaning on the child who is sitting on the floor. The caregiver has the child's arm pulled over the child's head putting pressure on a child which impairs the breathing .


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

raw_content: One out of three children's records reviewed, one child's Preliminary Service Plan was not completed within 72-hours. The child was admitted on 5/17/21 and Preliminary Service Plan was completed on 6/1/21.

Correction Narrative: Received an email from the Director of Admissions and Compliance: All Preliminary Plans of Services (Standard 748.1331) have been completed. Going forward all Preliminary Plans of Service will be completed within 72 hours of Admission. At the 48 hour mark I will follow up with case managers to ensure that they are not late going forward.


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

raw_content: A caregiver used Emergency Behavior Intervention when it was not an emergency situation.

Correction Narrative:
requested an AR, extension granted. Operation emailed stating they completed additional EBI trainings.
11/15/2021 Follow up completed with Administrator by 11/15/21. New EBI policies are being implemented and the Administrator will no  longer engage in personal restraints.


summary: 748.105(7) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS

raw_content: Caregiver failed to report  a collages vulgar language towards a child as soon as she was informed of it.


summary: 748.2451(a)(2) - Emergency Behavior Intervention-Use personal restraint only if policies permit and requirements of this subchapter are met

raw_content: Staff members contained a child in a restraint that was not approved by operation policy.

Correction Narrative: Extension granted due to Administrative Review per PA Penelope Baldwin. On 11/15/21 A conference call with the Administrator and Director was conducted and the operation is writing new EBI policies to eliminate personal restraints. Personal restraints will no longer be used, they will include all de escalation methods that will be used by trained caregivers.


facility_name: Texas Girls and Boys Ranch

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

raw_content: A caregiver physically intervened by grabbing a child to thwart the child's behavior.

Correction Narrative: A voluntary corrective action plan was submitted ensuring that the operation addressed all concerns regarding disciplinary measures. Staff were canceled and revised on consistent behavior techniques that align with the operations model and promises. Staff will meet with the PD and clinical director 1 on 1 monthly, and house parents will receive monthly check-ins.


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

raw_content: Staff did not complete annual normalcy training timely.

Correction Narrative: The training coordinator audited the normalcy training for all active employees and the software update triggers. The employee of concerns completed and submitted their normalcy training on 5/16/25.


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: One children's rights record was not signed timely within 7 days of admission indicating  that the rights were not reviewed.

Correction Narrative: The GRO will ensure a signed copy of children's rights will be in the children's files within 7 days. The operation will perform quarterly peer reviews. All client files will be audited for errors. A memo will be added to the files as a part of the corrective action plan. The PD reviewed this information with all case managers to ensure that this information is in the admission packet.


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

raw_content: A child in care was administered medication prescribed to another child in care.

Correction Narrative:
A voluntary corrective action plan was submitted by the Administrator sating that the involved caregivers were verbally counseled on the importance of being alert, and aware while administering prescribed and over the counter medications to children in care. The caregivers were required to take additional training on psychotropic medications and basic medical.
I review the medication logs and storage at the time of this inspection, no concerns were identified.


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

raw_content: A caregiver admitted to sleeping when being the only caregiver on duty.


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

raw_content: Two cottages inspected had shower mold, door damage, splitting around door knob, and snack trash under a child s bed.

Correction Narrative: The operation met compliance by submitting photos of the cited repairs and a Voluntary Corrective Action plan.


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

raw_content: Six children in care at the operation, both males and females, ages 5-14 years old were subjected to ongoing sexualized contact by a caregiver.  Additionally, a caregiver failed to intervene to prevent the sexualized contact from occurring at the childcare operation.

Correction Narrative:
(Inspection# 393422): A physical follow up inspection was conducted on 3/7/2023 in correlation with the action plan submitted. A walk through of the cottages were conducted to ensure that the alleged personnel was no longer on the property. Records of the alleged personnel were reviewed to clarify the alleged personnel's termination dates. Discussions, amongst the administration and myself was conducted regarding the corrective action plan that was submitted. The administration explained in in detail how they will continue to implement the action plan to prevent any future risk.

The corrective action plan stated that all staff are required to review children's rights. The operation has reposted the children's rights posters in all cottages making them more visible. The operation installed cameras in the common area of the cottages to assist with unannounced supervision.


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

raw_content: A caregiver knowingly failed to report sexual abuse to the Child Abuse Hotline which allowed sexualized contact to continue be exhibited toward children by two caregiver(s) at the operation.

Correction Narrative:
(Inspection# 393422): A physical follow up inspection was conducted on 3/7/2023 in correlation with the action plan submitted. A walk through of the cottages were conducted to ensure that the alleged personnel was no longer on the property. Records of the alleged personnel were reviewed to clarify the alleged personnel's termination dates. Discussions, amongst the administration and myself was conducted regarding the corrective action plan that was submitted. The administration explained in in detail how they will continue to implement the action plan to prevent any future risk.

The operation created internal methods for children and adults to anonymously report concerns, or the violation of children's rights. The operation provided trainings on how to recognize, and reporting abuse, neglect, sexual misconduct, and responding to suspected behaviors. The operation provided trainings on identifying reportable incidents and the importance of timely manner.


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

raw_content: During the course of the investigation, it was determined that two operational caregiver(s) did not use proper judgement and did not demonstrate self-control in the presence of the children by engaging in inappropriate sexualized contact and behavior with six children in care.

Correction Narrative:
(Inspection# 393422): A physical follow up inspection was conducted on 3/7/2023 in correlation with the action plan submitted. A walk through of the cottages were conducted to ensure that the alleged personnel was no longer on the property. Records of the alleged personnel were reviewed to clarify the alleged personnel's termination dates. Discussions, amongst the administration and myself was conducted regarding the corrective action plan that was submitted. The administration explained in in detail how they will continue to implement the action plan to prevent any future risk.

Staff are required to review their job descriptions and children's rights at least one time a year. The intent of these requirements is to ensure competency, prudent judgment, and self-control of staff always.


raw_content: A 13 year child ingested over the counter medication and self reported the ingestion.  Caregiver required to provide supervision was unaware of the child's activity and access to medication.

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

Correction Narrative:
The Administrator submitted the BGC previsions for the staff person. It is clearly stated how staff will be utilized while at the operation until further notice. The staff will be accompanied by other staff always and never left alone with any child in care at any time.

Providing more staff, Service Plan changes, and internal adjustments will increase awareness of children in care. During the follow up inspection is was demonstrated how the supervision changes are being implemented.


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

raw_content: Child was able to access medication due to the medication being unlocked or the child having access to the medication keys.

Correction Narrative: A follow inspection was conducted, photos were taken. The operation has replaced all doors were the medication is locked and stored. Applying automatic locking doors and enforcing all staff to keep all operation keys on the staff person always.


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

raw_content: Caregiver did not provide a child in care with appropriate supervision when the child with high-risk behavior history was able to access and ingest medication without the caregiver's knowledge.

Correction Narrative: Administrator submitted a Safety Plan with supervision implementation for child in care. All required information is documented completely to describe how the child will be supervised by staff during awake and sleeping hours.


facility_name: Independence Farm

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

raw_content: The operation van inspection sticked expired 12/2025.

Correction Narrative: Valid registration received for operation vehicle.


summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: Two of two child records reviewed, did not include initial services plans.

Correction Narrative: Two of two child ISP received with dates and signatures.


summary: 748.3113(a) - Fire Extinguisher-Must have a fire-extinguishing system, which may be sprinkler system and/or fire extinguishers

raw_content: During the operation walkthrough, there were no fire extinguishers throughout the operation.

Correction Narrative: Op provided receipt of purchase and pictures of tagged fire extinguisher inside of operation.


summary: 748.158(2) - Operational Responsibilities- Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit

raw_content: The operation insurance expired 7/1/2025.

Correction Narrative: Proof of liability insurance received with effective date.


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

raw_content: Two of two child records reviewed, did not have admission assessments.

Correction Narrative: 2 of 2 child admissions records received with date and signatures.


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

raw_content: The caregiver did not follow the service plan for children that required line of sight supervision.

Correction Narrative: The staff indicated that they were retrained on service plans and ensuring that they are aware of each child's supervision plan.