summary: 748.1531(b)(5) - Medical Care-Written record of each medical examination includes any documentation provided by health-care professional who performed exam

raw_content:
The form 2403 to document the 6/4/2024 Texas Health Steps medical exam was not completed in its entirety.  Pages 6 and 8 were left blank resulting in required information left blank.  The Visit Results (page 6) and Follow Up (page 8) were not documented.

The form 2403 to document the 4/20/2024 Texas Health Steps dental exam was not completed in its entirety.  Pages 2, 4, 6, 7,8 were left blank resulting in required information left blank.  The Reason for Visit (page 2), Medication List (page 4), Visit Results (7) and Follow Up (page 8) were not documented.

The form 2403 to document the 6/4/2024 Texas Health Steps physical exam was not completed in its entirety.  Page 6 was left blank resulting in required information left blank.  The Visit Results (page 6) were not documented.

The form 2403 to document the 3/22/2024 ER Visit was not completed in its entirety.  Pages 4,8, and 9 were left blank resulting in required information left blank.  The Medications (page 4), Follow Up (page 8), Provider Information (page 9) were not documented.

The form 2403 to document the 4/22/2024 medical exam was not completed in its entirety.  Page 5 was left blank resulting in required information left blank.  The form was not signed by the caregiver and/or DFPS staff.

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


state: TX

facility_name: The Ambience Residential Treatment Center

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: Vehicle was missing a registration sticker. Registration (proof of purchase) paperwork stated 5/23/2023. It has been over a year since purchase date.

Category: Individual Standards Evaluated

Standard Risk Level: Medium Low

Corrected at Inspection: No

Correction Narrative: An email was sent on 07/24/24 with a picture of a valid vehicle registration that expires on 06/2025


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

raw_content: Multiple holes in the walls prompted a walk through. 8-10 inches in length and 4-5 inches in width. total number of holes 7. Multiple window blinds were also broken.

Standard Risk Level: Medium

Correction Narrative: An email was sent on 07/24/24 with a picture of the following repairs, several holes in the wall and blinds.


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

raw_content: The operations health inspection expired on 04/21/24

Correction Narrative:
The operations health inspection was
completed on 7/1/24.
The inspection has also been added to
our tracker to ensure we don't forget the
next due date.


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

raw_content: 2 out of the 4 child's files reviewed 72-hour plans were missing signatures.

Correction Narrative:
All affected Service Plans have been
signed.
To prevent a repeat, all incident reports
will be reviewed by the case manager
and LCCA before being issued out.


raw_content:
There were physical site concerns during the walk through.
-A room located upstairs electric plug was missing a cover.
-Blinds and the kitchen and a room located upstairs were damaged.
-There was water damaged on a ceiling located in room upstairs.

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

Category: Physical Site

Correction Narrative:
These damages have been repaired.
The kids tend to play and destroy these
fixtures during bedtime because their
beds are close to the wall.
Beds have been moved further away
from the walls, so they don't tamper
with these fixtures without staff seeing
them

(photos of the repairs have been uploaded).


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

raw_content: One staff members file reviewed did not contain documentation for reference checks.

Correction Narrative: An email was sent with the following correctives: The operation will ensure reference check forms are concluded before the employee's start date


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

raw_content: One staff file reviewed did not contain proof of education.

Correction Narrative:
An email was sent with the following information: 1.The operation will ensure all employee binder is updated with all required information (personnel)before the start date.
2.All documentation would be notarized before the employee's start date.


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

raw_content: The operation was not abiding by their pre-employment drug testing policy.

Correction Narrative:
An email was sent with the following correctives:
1. The Ambience RTC has moved from 3rd party conducting the Drug test to in-house Testing.
2. The operation conducts an in-house drug testing as part of the interview process.
3. The operation will update its drug testing policy documenting by end of Q1 2024


summary: 748.153(3)(C) - Notification - Remove controlling person

raw_content: The operation has not removed a controlling person as prompted by licensing since 11/07/2023.

Standard Risk Level: Medium High

Correction Narrative: The operation CEO updated the operation controlling persons and plans to review and update the operation controlling persons every 3 months moving forward.


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

raw_content: During inspection, bees were observed to be collecting behind the paneling of the house outside in the backyard.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: During the inspection, the operation was found to have an expired fire inspection.


summary: 748.3307(b)(1) - Physical Site-Habitable rooms must be lighted to avoid accidents

raw_content: During the walkthrough of the operation a child's room was observed to have no lighting in the closet and not enough lighting in half part of the room.


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

raw_content: During inspection, a child's bed was observed to be broken and not in good repair.


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

raw_content: During the inspection, all second floor windows were observed locked/screwed shut not allowing windows to be opened.

Corrected at Inspection: Yes


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

raw_content: During the time of inspection, the following was observed: an open package of bacon, an open package of sausage links, and unmarked meat.


raw_content: Operation walls were not observed in good repair as holes were observed during the inspection of the operation.


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: Children are not being allowed privacy when making phone calls to their Case Workers.

Correction Narrative: If a child in care does not require supervised phone calls, children in care will have phone calls in the staff office with staff still within eyesight yet out of hearing range or the Therapy room when it is available.


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

raw_content: A medication log is missing and there is no evidence that child took medication as prescribed.


Standard Number / Description: 748.3301(h) - Physical Site-The building must be free of rodents and insects

Deficiency Narrative: During inspection, bees were observed to be collecting behind the paneling of the house outside in the backyard.


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

raw_content: During inspection, a med log for 1 child in care reviewed did not document the name and signature of the staff that administered the medication.


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 employee fille reviewed during inspection was not found to have a notarized licensing affidavit.

Category: Reports and Record Keeping


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

raw_content: Operation walls were not observed in good repair as five holes were observed during the inspection of the operation.


raw_content: The following was observed during the inspection, a package of expired ham, left over cream cheese in the original foil wrapper but exposed to other foods, 1 rotting tomato, open unwrapped sliced cheddar cheese log, unknown meat in an unmarked ziploc bag, and blueberries and bluberry debris in the freezer.

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


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

raw_content: Caregivers did not provide a safe environment when 2 upstairs windows were broken and plywood was set loosely inside the window frame.

Standard Risk Level: High

Correction Narrative: The physical operation was observed to be safe, clean, and organized on 12/20/2023. The operation will not implement unsafe, temporary or permanent, solutions to the physical operation without consulting licensing and/or other regulating professionals and/or officials.


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

raw_content: The operation did not report serious incidents related to law enforcement responding to incidents at the facility and children in care being arrested to the hotline and/or parents.

Correction Narrative: The operation conducted a meeting on 12/12/2023 with all operation staff and reviewed operation policy and procedure for serious incidents to include notifications, reporting, and documentation. The operation's follow through with their corrective action plan was confirmed during inspection through reviewing documentation and interviews with staff.


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

raw_content: A debriefing is not being conducted and/or documented with children in care following running away and returning to the operation. This was observed for 17 incidents reviewed.

Correction Narrative: The operation developed and implemented an Unauthorize Absence Debriefing Form which staff will be using to document their debriefing with a child in care. The operation conducted a meeting with all operation staff on 12/12/2023 to review operation policy and procedure for conducting and documenting debriefing with a child in care upon their return from an unauthorized absence. Operation corrective action plan was confirmed during inspection on 12/20/2023 through interviews with staff and documentation.


summary: 748.457(a) - Unauthorized AbsenceTriggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: The operation is not conducting triggered reviews for 3 children in care who ran away 3 times in a 60-day period.

Correction Narrative: The operation administration team (owner, administrator, and case manager) met, reviewed the rule, and developed and implemented an unauthorized absence triggered review form that will be used moving forward if and when children run away 3 times in a 60 day period. A meeting will be conducted with the team along with the child's CPS caseworker to discuss the occurrences, develop and implement a safety plan, and decide whether or the not the placement continues to be in the best interest of the child. The unauthorized log and serious incident reports were reviewed on 12/20/2023. There were no unauthorized occurrences and/or need for a triggered review at the time of inspection.


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

raw_content: The operation has not completed an evaluation related to run aways for a six month period.

Correction Narrative: The operation administration team (owner, administrator, and case manager) met and developed an Unauthorized Absence 6-month evaluation form. The evaluation was completed on 12/21/2023 and will be completed every 6 months thereafter. The operation created a future operation calendar prompt as a reminder to complete the evaluation in 6 months.


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

raw_content: The operations annual summary log was observed to be missing a child's name, age, gender, and date of admission for 10/8/2023.

Correction Narrative: The operation Executive Director submitted a corrective action plan on 12/06/2023. Moving forward, the operation Program Director/LCCA will review the operation unauthorized absence summary log monthly to ensure omissions or errors are observed and corrected.


summary: 748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly

raw_content: The operation did not have documentation to show the operation fire extinguishers were being inspected monthly.

Correction Narrative: corrective action plan was submitted via email


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

raw_content: At the time of the inspection, one of the upstairs bathrooms was found to not be maintained in good repair as the cabinet floor under the sink was observed warped and moldy.

Correction Narrative: corrective action plan


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

raw_content: During the walk through of the operation the medication cabinet was not locked.

Correction Narrative:
Physical follow up was conducted at the operation on 12/20/2023.  Medications were verified as being appropriately stored and locked during the inspection.

Medications at the operation are stored in a locked cabinet located inside the med closet, that is always locked, in other words the medications are doubled locked. The only time the lock is open is when medication is being administered or when an adult is going in. As an additional measure to satisfy this CAP, staff have been required to lock the med closet even during an administration or adult, when the meds are not in the closet.


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

raw_content: During the walkthrough of the operation holes on the wall were observed in a child's room.

Correction Narrative:
A physical walk thru was conducted of the operation on 12/20/2023.  No holes were observed in the facility and previous damages were repaired.

The operation has placed a DIY policy to fix all holes in walls in house by the LCAA or Directors. 5 mm plywood boards and 1 gallon of paint are in the stock in the garage. Staff shall report every hole immediately and LCCA or Director will fis them within 24 hours.


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 child in care was left unsupervised due to the child care provider being locked out of the facility.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

The locks of the facility main doors have been changed from the electronic keypad lock to a manual key and the staff on shift must always have these keys on themselves. This was verified during the physical inspection. This has eliminated the risk of clients knowing the access PIN and ability to disable to lock by removing the battery, as was the case when this incident occurred. The current agency policy requires that an admin staff shall not double as a caregiver during office hours except during emergency situations. In addition, one of the directors is always available on call. Executive Director stated that he lives close to the operation, and he is available if needed.


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

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

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

Executive director stated that the operation was able to be identified who the person yelling and using profane language towards the children was and parted ways with the employee for that reason. Staff background was seen to be inactive and no longer employed with the operation. Staff members interviewed stated that the operation has provided and reminded the staff with de-escalation and re-direction techniques. Operation provided a training sign in sheet for discipline training.


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

raw_content: During the course of the investigation it was determined that a child in care was subjected to corporal punishment by being pushed by staff.

Correction Narrative: During the inspection, three children in care were interviewed and three out of three children stated they felt safe and were being treated well by staff. There were no concerns with corporal punishment.


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

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


summary: 748.2855(c) - EBI Documentation-If personal restraint, must include specific restraint techniques used, including prone/supine restraint used as transitional hold

raw_content: There was no documentation stating the child in care was put in a restraint by a staff who advised he a placed the child in a restraint.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

A training sign in sheet was provided for 9/15/2023. Serious incident report form was updated to include sections for EBI Documentation and the requirements.  Staff were interviewed and asked questions on the training. Staff members were able to identify what should be documented as part of the EBI documentation and expectation on completing serious incident reports by the end of their assigned shifts.


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: A staff admitted to a case worker to using an inappropriate restraint towards a child in care by placing his arms behind his back.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

Prior to the training of 9/15 staff were given a refresher on EBI. On the current training on 9/15 staff members were once again refreshed on EBI implementation. Staff members interviewed were asked questions on the holds permitted to be used. Employees showed knowledge on the holds and are aware that EBI is used as last resort when a child is in immediate danger to themselves or others. Staff members interviewed stated that it would be incorrect to place any limb of a child behind their back. They have not seen or witness any one at the operation conduct an inappropriate hold on a child.


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

raw_content: Multiple Medication logs were missing for 2/14/22-23 and  2-8-23.

Correction Narrative:
After reviewing a child record. A medication log was found to have missing dates.

Operation records reviewed; the operation does random audits to ensure that the medication logs are completed. Operation now does monthly logs 30 or 31 days per medication to avoid confusion. Medication logs are stored in the child's file after the 30 or 31 per month, medication logs no longer run continuously.


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

raw_content: There were no supporting documents stating the child had taken the medications from the missing logs.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: There were 5 childrens records that did not have identifying information easily accessible.

Correction Narrative: The operation sent me an email with pictures that the holes in the walls had been repaired and the face sheets were added to the children's records.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: Operation did not document EBI documentation on serious incident report.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

A training sign in sheet was provided for 9/15/2023. Serious incident report form was updated to include sections for EBI Documentation and the requirements.  Staff were interviewed and asked questions on the training. Staff members were able to identify what should be documented as part of the EBI documentation.


raw_content: There were children that were exposing themselves and the night caregiver did not take the appropriate preventative measures. The night caregiver was aware of the incidents and did not take steps to separate the children.

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:
Follow-up completed by inspection id#3972206.
Follow-up details:

Operation implemented grouping of children with similarities together to avoid any type of child-on-child aggression and to avoid sexualized behaviors. During the physical follow up inspection children were observed to be in three different groups doing different activities. Sleeping arrangements have also been made for children that have sexualized behavior history. Staff were noted to be present outside of the children's bedrooms. Staffed interviewed also explained that they are to report any behaviors right away using an incident report form by the end of shift no exceptions.


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

raw_content: Staff member did not use self-control when redirecting children in care and tossed the child on the bed.

Correction Narrative:
Follow-up completed by inspection id#3972206.

Follow-up details:

Staff present were interviewed and were asked about trainings provided by the operation regarding redirection and self-control. A copy of the training sign in sheet was provided at the time of inspection the training took place on 9/25/2023.

Staff present showed knowledge regarding the topics discussed on the training regarding re-direction. Staff stated that the training consisted of when to conduct an emergency behavior intervention, topics on redirection and documenting serious incidents. Staff also stated that they are not to use any type of physical force, or any type of physical discipline and that has been addressed with the operation since the time of hire during orientation.


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

raw_content: A serious incident report was not documented or provided for an incident in which children in care were having behavioral problems during the nighttime.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

Executive director stated that the operation has re-created serious incident report form and included a section for documentation as to the requirements needed for a serious incident report would need. Executive director stated that the same form will be used for incidents that do not constitute a serious incident report and are more behavioral incidents. A copy of the previous/current Serious incident form was obtained. Executive Director also stated that staff were reminded about reporting and documentation through the meeting on 9/15/2023. Staff are expected to complete Serious Incident form and reporting within 24 hours. Staff interviewed stated the expectation the operation has implemented is to have any serious incident reports/non-serious incident report are to be completed as soon as possible before their shift is over. The report is to be filled out by the person with firsthand knowledge and the report must be detailed.


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: Operation did not report to licensing allegations of physical abuse towards a child in care.

Correction Narrative:
Follow-up completed by inspection id#3972206.
Follow-up details:

Conversation was held with executive director. Executive director stated that the operation has re-created serious incident report and include a section for documentation as to when the serious incident was reported to licensing. A copy of the previous/current Serious incident form was obtained. Executive Director also stated that staff were reminded about reporting to licensing through the meeting on 9/15/2023. Staff are expected to complete Serious Incident form and reporting within 24 hours.


summary: HRC42.059 - Employment Affidavit

raw_content: There were several employees that are direct care staff that do not have their affidavits notarized.

Standard Number / Description: HRC42.059 - Employment Affidavit


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

raw_content: There was a drawer that was broken in one of the child's bedroom.

Correction Narrative: Operation sent me a picture that the drawer had been fixed.


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

raw_content: The operation did not submit their quarterly EBI for the third quarter as recommended at the 11/22/2022 monitoring inspection.

Category: Emergency Behavior Intervention

Correction Narrative: they submitted their EBI report and set a calendar reminding them.


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

raw_content: The operation was observed to have chemicals stored under the kitchen sink.


summary: 748.3703 - Recreation responsibility-provide indoor & outdoor recreational areas & equipment with sufficient variety & quantity

raw_content: The operation did not have any outdoor recreational equiment.

Category: Recreation Activities

Correction Narrative: They sent a receipt showing that the operation bought equipment.


facility_name: Graceful New Beginnings, LLC

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

raw_content: Children in care reported being denied access to phone calls as a form of punishment.

Correction Narrative:
The operation indicated that they will allow the children to make all requested phone calls to their caseworkers. They will have access to call and dial numbers of their choice to contact caseworker.
During a follow-up visit at the operation on 12/31 multiple children were spoken to about being the ability to make phone calls and no additional concerns were found.


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

raw_content: Documents that were initially requested on 11/13/25 were never received.

Correction Narrative: Graceful New Beginnings will contact each investigator by phone to confirm that all documents have been received as needed and document time spoken to along with date. If told the investigations are blended, confirmation with both investigators will be verified in the same manner.


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

raw_content: After multiple, recurrent incidents of unauthorized absence, the operation and caregivers have failed to implement safety plans or increased supervision to prevent further incidents of unauthorized absence.

Correction Narrative: The safety plan included special transportation provided by the school and when that became unsuccessful, they implemented staff to transport the child back and forth to school. There are 8 direct care staff on schedule with staggering shifts to help supervise the 3 children that are in care.


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

raw_content: The operation failed to properly document unauthorized logs in the annual summary log. The operation was not documenting Age, date of admission, CCR Report number or police information.

Correction Narrative: the review of the AWOL summary log shows to have all the required information. Triggered reviews were not needed as the children were discharged before the requirements were met.


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

raw_content: The operation failed to conduct a debriefing or document the child's refusal for a debriefing after multiple unauthorized absences,

Correction Narrative: The documentation reviewed showed a debriefing was requested and documented correctly according to the minimum standard requirements.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: A suicide attempt was not reported to licensing as soon as the operation was aware.

Correction Narrative: Email received with corrective action plan of updated policy of how suicide attempts will be reported.


summary: 748.311(9) - Serious Incident Documentation-Includes treating licensed health-care professional's name, findings, and treatment, if any

raw_content: A serious incident report dated 10/16/2025 for a child in care did not document the who provided and where the child received treatment.

Correction Narrative: The agency updated the incident report to prompt documenting any medical attention and treatment.


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

raw_content: The operation does not currently have a Licensed Child Care Administrator

Correction Narrative: Received an email from owner Grace Davis that she hired an administrator Ayesha Dolford and was having trouble adding her online. I have gotten her added and uploaded the email in the document library.


summary: 748.1209(b)(13) - Child Orientation-Include internal grievance procedures

raw_content: The orientation document currently being utilized does not encompass all of the necessary subject matters such as the grievance policy and gifts.

Category: Admission, Service Planning, Discharge

Correction Narrative:
GNB board has approved a new grievance policy for youth. This amendment has been added to the youth handbook.

 A protocol on how to receive gifts has been taught to all youth as of 2025 and will be used as a part of orientation moving forward 2/26/25.


summary: 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate.  At minimum must give copy to child 14 years and older

raw_content: Out of 3 child files reviewed, one child file is missing the child's signature on the service plan form indicating that the information was not shared with the child.

Standard Risk Level: Low

Correction Narrative: : All youth have read and was allowed to question their service plan.  A signature has been obtained and is in the youth's file.  In the future, the youth will discuss the service plan with an admin within 24 hours of the service plan meeting and provide signature.  Youth will continue to attend meetings if desired.


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

raw_content: Out of 5 child discharge records reviewed, they are all missing the discharge summaries.

Correction Narrative: A new document was created within the presence of the evaluator and approved for future use on 2/21/2025. Document will be a part of exit packet moving forward.


summary: 748.3115(2) - Fire Extinguisher-Must ensure fire extinguishers are accessible for immediate use by employees, caregivers, & volunteers

raw_content: During the inspection, it was found that the fire extinguisher was missing from the wall on the 2nd floor of the building.


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: Out of 3 child files reviewed, one child file did not contain information that the child's rights were reviewed with the child and properly documented in the child file.

Category: Children's Rights

Correction Narrative: All youths have been provided with the child rights form, and it is included in their intake information.  This will be requested from all SSC's upon intake and discussed and signed by youth during orientation.


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: During a walkthrough of operation, it was found that the fire inspection certificate was expired.

Correction Narrative: The inspection was scheduled for 2/22/2025 and completed on 3/5/2025.


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

raw_content: Out of three child files reviewed, one child file is missing an admission assessment form in their file.

Correction Narrative: Admissions are completed prior to a child arriving at the operation. For Emergency admissions a protocol was created in which all assessments will be completed within 24 hours and placed in the case file.


raw_content: In reviewing the Resident AWOL Log, it was found that the AWOL log was missing the child's date of admission, gender, amount of time child is gone, staff present.

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


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

raw_content: Out of 3 staff files reviewed, 2 staff are missing their Tuberculosis Skin Test Results. Staff must have their TB test completed and a record of the test results must be located in the staff file.

Correction Narrative: A new protocol was put into place in which all employees are required to submit a copy of a negative TB test upon hire.


raw_content: Records related to an investigation was requested from the operation by Licensing three times via email, and twice verbally. Records were not provided.

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

Correction Narrative: Grace Davis reported that the agency has put a protocol in place regarding providing records to licensing. Lakeshia McDonald or Ayesha Dolford are the contact persons for requesting records. The records are provided immediately if on site or emailed if not on site. The owner is also on-call 24- hours to address any requests. Records will be provided within 24-hrs or the next business day. This may have been an email issue.


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

raw_content: After reviewing documentation, it was found that one resident was never administered a suicide screening.

Correction Narrative: Child Care Licensing received a compliance plan from the operation stating that suicide screenings will be added to the intake forms upon the arrival of a child. They will be using the C-SSR screening tool.


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

raw_content: During review of records, there was no summary log for unauthorized absence documented for two children in care. In addition, there were no debriefs documented for unauthorized absences.

Correction Narrative: The operation created an AWOL log as required by minimum standards. This log will be maintained by the administrator.


summary: 748.2151(c)(7) - Medication record - must include the child's refusal to accept medication

raw_content: Medication logs were reviewed and revealed that a child in care was missing dosages and was not documented on the medication log after the child in care's medications had been filled.

Correction Narrative: The operation has created a medication incident log that will be completed when a medication error occurs. A copy of the medication incident log was uploaded into the document library.


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

raw_content: During the course of the investigation, it was determined that children were not properly supervised.


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 a caregiver did not exhibit prudent judgement when they gave a child a cigarette.


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

raw_content: It was determined that the operation failed to report a serious incident..

Correction Narrative:
An email was sent on 03/06/24 with the following correctives: From this point on  we the board of directors, director, staff will ensure that all reportable incidents will be called in to the crisis hotline so we will have a case number or reference number to place on our incident reports.
All future incident reports will have a space on it to place the reference or case number which prompt the staff making the decision.
to call 911 or local sheriff that space will be filled in.


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

raw_content: There were bed bugs found at the operation.

Correction Narrative: During inspection # 3985067 on 1/22/2024 the operation changes were observed including new metal beds and bedding for all rooms. The operation self-treated for bed bugs with store bought spray and was sprayed professionally by an exterminator. On 02/16/24 emailed received stating Graceful new beginnings replaced the wood beds with metal beds. We had a pest control come to GNB sprayed the entire common area and all bedrooms, along with treatment that would prevent further invasion of bedbugs. GNB will continue treatment every six months to control the breakout of bedbugs again.


raw_content: During the inspection it was found that two staff records are missing TB skin test results.

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

Correction Narrative: During the inspection it was observed that the TB skin test was obtained


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

raw_content: During the inspection it was found that a child's record did not have a completed initial service plan. The child was admitted on 8/28/2023.

Correction Narrative: An email was received from the operation with the completed service plan.


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

raw_content: Two of two staff records did not contain a statement for employees to immediately report ANE.

Correction Narrative: This inspection took place during the operations first initial period. During the second initial period this standard was reviewed, see inspection #3973185


summary: 748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs

raw_content: The preliminary plan did not include the possible side effects for medication and no information about supervision.


summary: 748.1209(b)(13) - Child Orientation-Include internal grievance procedures

raw_content: Orientation provided did not contain information about visitations, mail, internal grievances, how to make complaints outside of operation, EBI, or personal possessions.


summary: 748.1217(b)(12) - Admission Assessment-At admission, must include services the operation plans to provide to the child

raw_content: The assessment didn't contain information on what services the operation plans to provide. It was also missing information about specific behaviors, trauma, as well as short and long-term goals.


summary: 748.3273(5) - First Aid Kits-Each one must contain multi-size adhesive bandages

raw_content: During the inspection, the first aid kit only contained cotton balls, a thermometer and a first aid guide.

Correction Narrative: The operation provided pictures of three brand new first aid kits


raw_content: Fire inspection expired in February.

Standard Number / Description: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

Deficiency Narrative: Fire inspection expired in February.

Correction Narrative: The operation has changed its location. The fire inspection for the new location was provided on June 14, 2023.


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

raw_content: The incident report is missing an area to document any child and adult witnesses. It is also missing the physical address and phone number of the facility. The form is also missing the age, gender, and date of admission.

Correction Narrative: The operation emailed an updated copy of incident report that includes all missing components.


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

raw_content: During the inspection the staff file was missing the TB exam results. The agency sent the staff out as of last week to be tested,

Category: Child Care

Correction Narrative: The agency responded with the TB results for the current employee. The agency will continue to follow the standards by ensuring every employee hired will have the TB test done in a timely manner.


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: During the inspection the staff file was missing the current drug test. The agency sent the staff to be drug tested as of last week.

Correction Narrative: The agency responded with the drug test results for an employee hired. The agency plans to continue complying with the minimum standards to ensure that all future employees will be tested in a timely manner.


raw_content: During the inspection the child records and logs were missing the refusal section.

Standard Number / Description: 748.2151(c)(7) - Medication record - must include the child's refusal to accept medication

Category: Medication

Correction Narrative: The agency responded with a new form to adhere to medication being documented and refused by a client.


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

raw_content: During the inspection the reason for the prescription given  was missing.

Correction Narrative: The agency responded with a new form that will keep record of medication being prescribed and the reason for it.


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

raw_content: During the inspection the staff file was missing the date of hire.

Correction Narrative: The Agency has responded with a new form to adhere to all employees hiring methods.


summary: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name

raw_content: During the inspection the prescribing doctor name was missing.

Correction Narrative: The agency responded with a new form that will keep record of medication being prescribed and the professional's name.


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

raw_content: During the inspection the third row seating needs to be maintenance so it can go up and down to accommodate the future capacity.

Category: Transportation

Correction Narrative: The agency responded with having the vehicle serviced to ensure everyone riding in the truck would be safe at all times.


facility_name: Kid Net Foundation dba Jonathan's Place

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

raw_content:
The medication logs were not current during the time of the inspection.

A PRN medication was administered six times without the time or reason being documented.

Six different medication logs reviewed did not have completed medication counts daily.

There was a medication that was administered to a child in care without being documented on a medication log.

Correction Narrative: The medication log was current during today's inspection.


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

raw_content: The operation failed to report a child in care was transported by EMS and hosptilized.

Correction Narrative: The operation has since made an self report regarding an different incident.  The operation now has plans in place to ensure all reports are made timely.    The operation is having a training March 17 for all staff regarding SIR and report.


summary: 748.1207(a)(2) - Placement agreement-Must include a medical consent form signed by a person legally authorized by Texas Family Code to provide consent

raw_content: Two of two children's records reviewed did not have a signed medical consent.

Correction Narrative: No children are allowed to be admitted into the operation without the signed document.


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

raw_content:
A medication is being administrated not according to the label instructions.

There was a second medication that did not have a prescription label on it to indicate how the medication should be administered.

Correction Narrative: The prescription medication was labeled and being given according to the label directions.


summary: HRC42.048(b) - AP Restrictions on the License (Type of Children, Age Range)

raw_content: The operation did not follow the conditions on the permit when the upstairs center space was used as activity space and children were observed to be playing.

Correction Narrative: At the time of the inspection, the center space was not being used for activity space.


raw_content: The operation did not follow the conditions on the permit when the upstairs center space was used as activity space and two children were being cared for in the space.

Standard Number / Description: HRC42.048(b) - AP Restrictions on the License (Type of Children, Age Range)


summary: 748.2301(b)(5) - Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated

raw_content: A caregiver forcefully pulled a toddler to get a TV remote from the toddler's hands which resulted in the toddler knocking over hot coffee.   The level of force used on the child was not warranted based on the severity level in a toddler having a TV remote in their hand.

Correction Narrative: In-Person retraining is scheduled for Jan. 22, 2026 for all staff.


raw_content: The operation did not follow the conditions on the permit when the upstairs center space was used as living space and a toddler was being cared for in that space.   The caregiver was also utilizing the restricted space to eat and watch TV in.


summary: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force

raw_content: A caregiver shoved a toddler causing them to fall to the floor instead of using a less forceful technique such as blocking the toddler.


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

raw_content: A caregiver had a cup of hot coffee sitting on the floor between herself and a toddler in care resulting in the toddler spilling the hot coffee onto the floor which could have resulted in burns.


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

raw_content: A Medication log does not have written down the month the PRN medication was administered to a child in care.

Correction Narrative: Thre PRN medication log reviewed during the inspection now included the month.


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

raw_content: The medication log for September 2025 is missing a signature/ initials September 11, 2025. According to the pill count it is believed the medication was administered.

Correction Narrative: The medication logs reviewed during the inspection had the initials and signatures of the person administering the medication.


summary: 748.685(b)(1) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's age

raw_content: A caregiver left an infant unattended on the bed to grab clean clothes before bath time, which resulted in the infant slipping off the bed and receiving carpet burn to the left side of their face.

Correction Narrative: The agency presented  compliance plan, which included verification of an equipped diaper changing station, usage instructions, and photographic documentation.  Kid Net organized training sessions for their staff, focusing on the proper usage of the changing table. The employee involved in the investigation received a reprimand and participated in extra training to address the concerns raised.


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

raw_content: Caretaker yelled at children in care.

Deficiency Narrative: Caretaker yelled at children in care.

Correction Narrative:
Action Plan for Compliance:
We are implementing a comprehensive training strategy to ensure all staff members are properly trained and retrained in Trauma-Informed Behavior Interventions (TRBI) and Managing Aggressive Behaviors. The training department will facilitate weekly "Lunch and Learn" sessions at noon, providing an informal and supportive environment for staff to refresh their skills and knowledge, as well as participate in ongoing discussions and check-ins regarding the management of challenging behaviors.
Leadership personnel, including Case Managers, lead direct care staff, the Assistant Director, and the Director, will be tasked with providing additional oversight and support to caregivers. This will ensure that staff members are equipped to work effectively with youth experiencing trauma and that a more collaborative and supportive approach is adopted in daily interactions.
Feedback mechanisms will be established to allow staff to voice concerns or suggestions regarding the implementation of the training and any challenges faced in applying these new strategies. This feedback will be reviewed regularly to facilitate continuous improvement and adherence to best practices in child care.
We will establish a monitoring system to evaluate the effectiveness of these trainings and support mechanisms. Regular assessments will be conducted to ensure that the strategies are being employed correctly and to identify any additional areas requiring attention or improvement.


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

raw_content: One staff member supervised 9 children in care including a child under the age of 5.

Correction Narrative: RCCR received the following compliance plan related to ratio: Director and lead direct care staff will ensure two staff are working shifts when there are 9-16 children in care. Direct care staff will communicate with the Director and/or lead should they need to leave their shift.


summary: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

raw_content: The children's living area was set up to have couches and various chairs throughout the open space between child rooms and bathrooms. This creates a rule violation.


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: The child did not sign the child's rights from within the allotted timeframe.

Correction Narrative: Documents were updated and now in compliance. To achieve compliance with the minimum standard, the Case Manager will ensure that all children will review, sign and date their rights within 48 hours of admission. Assistant Director/Director of Residential Programs will ensure this is complete and uploaded in extended reach.


summary: 748.1205(a)(15) - Admission Documentation-Includes a copy of the placement agreement, if applicable.

raw_content: The placement paperwork was signed after the children were moved to a different location.

Correction Narrative: Documents were updated and now in compliance. To achieve compliance with the minimum standard, the Case Manager will ensure that all placement agreement forms are signed by CPS either prior to admission or signed within 24 hours of admission.  Assistant Director/Director of Residential Programs will ensure this is complete and uploaded in extended reach. The administrator will ensure that DFPS/SSCC's have been notified at least 7 days prior to moving, provide the new resource number, and to not move any children to a new location until new placement paperwork has been received.


summary: 748.1203(b) - Admission-Placement must meet child's physical, medical, recreational, educational, & emotional needs as identified in admission assessment

raw_content: The placement authorization was not completed within the timeframe.

Correction Narrative: Documents were updated and now in compliance. To achieve compliance for this standard, the Case Manager will ensure that all Admissions/placement documents are signed by CPS either prior to admission or signed within 24 hours of admission. Assistant Director/Director of Residential Programs will ensure this is complete and uploaded in extended reach.


summary: 748.1207(b) - Placement agreement - Must be signed by parent

raw_content: The placement agreement was not signed on the day the children were placed at the new location.

Correction Narrative: Documents were updated and now in compliance. To achieve compliance with the minimum standard, the Case Manager will ensure that all placement agreement forms are signed by CPS either prior to admission or signed within 24 hours of admission. Assistant Director/Director of Residential Programs will ensure this is complete and uploaded in extended reach.


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

raw_content: The application requested to offer services for Childcare, Autism Spectrum Disorder, Intellectually Developmental Disabilities, Respite Care, Emergency Care Services, and Young adults in Care. The Admissions Policies include admission procedures for HT, Assessment Services, and Emotional Disorders.

Category: Organization and Administration

Correction Narrative: An updated application was recived with the updated/added services for the operation listed for Child care services, emergency care services, transitional living program, assessment service, emotional disorders, intellectual disability, autism spectrum disorder, young adult care and human trafficking services.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: This rule was not addressed.

Deficiency Narrative: This rule was not addressed.

Correction Narrative: The agency added non-employees to the training list.


summary: 748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases

raw_content: This rule was not addressed in the policies and procedures.

Correction Narrative: An email was received outlining that the operation will highly encourage employees to get vaccinated, but they are not required to get vaccinated for the flu and COVID-19. The policy outline procedures, prevention and disciplinary actions for COVID-19 and the flu.


summary: 748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet

raw_content: The evacuation diagram does not demonstrate meeting locations outside of the building.

Category: Safety and Emergency Practices

Correction Narrative: An was received with a PDF file attachment with the evacuation plan diagram depicted the meeting place will be at the basketball court on property.


summary: 748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers

raw_content: The procedures for childcare ratio do not explain how the policy for treatment services ratios will be implemented.

Correction Narrative: The operations caregiver ratio policies now state that, "The child/caregiver ratio is the maximum number of children for whom one caregiver can be responsible. In GRO, a single caregiver may care for eight children, if any require treatment services the ratio decreased to five children per one caregiver. Children under the age of five count as two in the ratio. Ratios apply to children and adults in care."


summary: 748.101(3) - Plans to submit - sketch of operation's floor plan

raw_content: The floor plan documents the purpose of most rooms except for bedrooms. It is assumed that bedrooms are listed as rooms only.

Correction Narrative: An email was received with an PDF attachment of the revision of the operations floor plan with each room's purpose labeled.


summary: 748.113(2) - EBI policy - the specific techniques that caregivers can use

raw_content: The policies did not state what types of restraints will be implemented.

Correction Narrative: An email was received with the training diagram of the type of restraint/hold that the operation staff will be using. The training  curriculum is MAB (managing aggressive behaviors)


summary: 748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest

raw_content: The conflict-of-interest policy is missing this statement. It also does not address how your employees will avoid conflicts of interest with the families of children placed.

Correction Narrative: The operations conflict of interest policies include the statement "Most members of the governing body must comprise of people who do not have a conflict of interest".


facility_name: Letot Center

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

raw_content: A caregiver left children unsupervised during the night shift resulting in children engaging in inappropriate behavior.

Correction Narrative: A safety plan was implemented and 1 child was discharged from the program.


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

raw_content: There was a two-hour delay in getting a child medical attention, after the child injured their head.

Correction Narrative: I, RCCR Tommie Moore receive an email from administrator. A memo was sent showing Letot supervisors and staff signed a memo regarding reporting injury and illness. The memo can be found in document library.


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

raw_content: During the walk through of the operation, there were two sinks that had one broken handle for the faucet in the girls and boy's bathroom.

Correction Narrative: A work order was submitted the same day and was repaired on 5/13/24 for the repair of Girls' Restroom 314 and Boys restroom 327.                                                          Photos were provided by the operation.


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

raw_content: The operation does not have a licensed administrator.

Correction Narrative: I, RCCR Tommie Moore received an email stating that administrator Leah Probst had taken her administrator test and passed.


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

raw_content: One employee did not have a notarized in file.

Correction Narrative: RCCR received the employee notarized from the operation. The operation stated that the form was completed in June 2022. It was misfiled. The notarized form can be found in share drive.


facility_name: Kinship Konnection, LLC

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

raw_content: A child's medication review recommended a medication be given 2 times a day at double the original dosage, however the child continued to receive the medication 3 times a day at the original dosage prescribed by a medical professional.

Correction Narrative: It was determined during this inspection that the child is receiving medication as prescribed by a health-care professional.


summary: 748.457(a) - Unauthorized Absence - Triggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: A child had 3 unauthorized absences, and the trigger review was not completed.

Correction Narrative: The LCCA emailed over the child's runaway prevention plan that was completed on 11/17/2025. The prevention plan was reviewed and is in compliance as all the required information is addressed. The plan has been uploaded to document library. The LCCA also emailed the child's trigger review service plan that was completed on 12/02/2025, which has been uploaded to document library.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: Dirt in the pantry was observed; cleaning did not resolve.

Correction Narrative: A picture of the pantry was sent via email. The pantry was observed to be clean with a fresh coat of paint.


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

raw_content: One employee was observed to have a CPR certificate that expired.

Correction Narrative: CPR training certificate for staff of concern was provided during follow up. Operation is in compliance.


summary: 745.8411(b)(2) - Responsibilities - Provides access to all areas of the operation

raw_content: Upon arrival for inspection (10:20am), the home was empty, and no staff was available to allow us to enter the operation.

Correction Narrative: Operation is now in compliance.


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: One employee file reviewed did not contain documentation showing that all previous employers were contacted.

Category: Personnel

Correction Narrative: References for staff of concern were provided during follow up inspection. The operation is now in compliance.


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

raw_content: Couches in the living room were observed with exposed cushioning and the left side back of the couch is broken.

Correction Narrative: The operation disposed of the couch that was observed to be broken. The operation ins now in compliance.


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

raw_content: One employee was observed to not have a high school diploma in his employee file.

Correction Narrative: The operation is now in compliance.


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

raw_content: Pre-Employment Affidavit was observed to not be in one of the employee files.

Correction Narrative: Pre-Employment Affidavit was provided. The operation is now in compliance.


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

raw_content: The vehicle used to transport children was observed with three cracked windows, the air conditioner did not work past the front two seats, rear passenger seats were observed to be lifted from the floor and able to overturn, both passenger side tires with worn tread, no covering on the floor or side door panels exposing metal, broken seat belt covers, the foot board being held up with zip ties, and trash throughout each row.

Correction Narrative: The operation has acquired 2 new vans and per staff and child at operation, the white van originally cited for is no longer in use. The operation is now in compliance.


raw_content: The floor of the pantry was observed to be dirt. During a visit on 9/11/2025, a warning was given regarding the condition of the floor in the pantry, furthermore, the same issue was noted in the health inspection report. We also observed staff pick up a bag of chips that was stored on the ground in the pantry upon opening it for inspection.

Standard Number / Description: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair


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: One employee file was observed to be missing a preemployment drug screening.

Correction Narrative: The operation is now in compiance.


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

raw_content: Observed multiple names on the people list classified as employees that did not appear on the staff roaster that was provided.

Correction Narrative: Background checks have been updated to match staff list, operation is now in compliance.


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

raw_content: The operation did not write an incident report for the incident.

Correction Narrative:
10/03/2025-The LCCA submitted to Licensing staff via email the operation's corrective action plan, which consisted of the serious incident documentation related to serious incident described in the allegation narrative.  The submitted documentation contained all required components and was determined to be in compliance with Minimum Standards.

Additionally, the LCCA disclosed the operation will be requesting an administrative review.


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

raw_content:
During the walk through i observed beef patties not being thawed out properly.

It was corrected by the staff placing the meat in a leak proof  bag and placing it in the refrigerator


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

raw_content: During the walkthrough, multiple mattresses were observed without waterproof mattress covers.

Correction Narrative: The mattresses that weren't waterproof were equipped with mattress covers.


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

raw_content: During the walk through, leftover construction supplies were observed upstairs , an electrical outlet in the floor of the living room was sunken in and appears to be unsafe, the floor of the pantry was grimy, and the recreation area /garage had a glass shard, trash, and wood pallets, additionally, a pipe was observed with duct tape hanging off of adjacent to a hole in the ceiling.

Correction Narrative: The operation appeared to be clean and in good repair.


summary: 748.3307(b)(2) - Physical Site-Common use rooms, such as dining rooms, living rooms, laundry rooms, and gymnasiums must be lighted to avoid accidents

raw_content: During the inspection, the game room adjacent to the front door was observed with no light other than sunlight.

Correction Narrative: The light observed to be working properly during the walk through of the operation.


raw_content: Multiple bunk bed rails were observed to be broken or missing.

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


summary: 748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection

raw_content: Operation failed to get a fire inspection conducted timely last inspection was 05/24/2024. Operation was previously cited on 7/17/2025 for this standard.

Correction Narrative: Fire inspection report was received via email.


raw_content: Top bunk bed safety guard rail is damaged and present a hazard to the children's safety.


raw_content: Operation failed to get a fire inspection conducted timely last inspection was 05/24/2024.


raw_content: During the walkthrough of the operation, several maintenance issues were observed, including damaged or missing blinds, chipped or missing baseboards, holes and chipped paint on walls, a loose upstairs doorknob, and a bathroom hanging off the hinges. Water was not running in one bathroom, and several tiles were missing from the kitchen floor.

Correction Narrative: An unannounced inspection was iniated at the operation. A physical site walkthrough was conducted. Several of the concerns mentioned originally have been corrected.


raw_content: Several elements were missing from one child involved incident report. Such as interventions used, both medical and any actions taken in response to the incident, The time frame the incident occurred, the child's age, and Date of Admission were also not included in the report.

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

Correction Narrative: Received corrective action plan from the administrator stating the following: In regard to the cited deficiency for 748.311- Serious Incident Documentation, a staff meeting was held on 7.8.2025 after an internal audit of our reports. During this meeting, they discussed detailed documentation. Included in the email was an attached Agenda. In addition, they ensured that they would continue to audit their files internally to strengthen our document process.


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

raw_content: The serious incident report was missing the address and phone number.

Correction Narrative: The Serious Incident Report was updated after inspection and placed in the Serious Incident Binder.


raw_content: The door to the refrigerator and the plastic basketball storage bin was observed to be broken.

Correction Narrative: An unannounced inspection was conducted, physical site has improved. All furniture/equipment was clean and in good repair.


raw_content: The kitchen drawers were stained and unclean, one of the children's bathroom smelled like urine, the paint on the laundry room cabinet was observed to be chipped and peeling off.

Correction Narrative: An unannounced inspection was conducted, operation was clean and in good repair.


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

raw_content: Operation failed to report quarterly EBI numbers for 1st quarter January-March 2025.

Correction Narrative: The LCCA has set a quarterly reminder for the 30th of each reporting month for the remainder of 2025 to ensure EBI's are reported in a timely manner.


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

raw_content: Broken glass pieces were observed scattered in the back yard of the operation.

Correction Narrative: The broken glass observed on the ground originated from a cracked trash can, which has since been discarded. To prevent future hazards, management will oversee regular checks using the building and grounds maintenance checklist to ensure any potential risks, such as broken glass, are promptly identified and addressed.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have "No Trespassing Signs" posted.

raw_content: No trespassing sign posted does not include all required information.

Correction Narrative: LCAA ordered HHSC trespassing sign in our presence (I,RCCR Inspector Natalia Alexander and Jassica Brunson)at monitoring inspection.


raw_content: Multiple damages to the property were observed during the walkthrough.

Correction Narrative: The damage observed during the walkthrough was immediately documented in a work order, and arrangements were made for repairs pending the contractor's availability. To reduce the likelihood of future incidents, the operation is reinforcing regular maintenance checks and promptly addressing any facility-related concerns. The contractor was on-site the evening of the inspection on 4/22/2025 to begin necessary repairs.


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

raw_content: File doesn t include Affidavit Form 2912

Correction Narrative: Operation had all staff sign form 2912 and has been added to the New Orientation packet for future hires.


summary: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

raw_content: A child in care incurred injuries during a restraint.


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

raw_content: A child in care was restrained with his arms pulled behind his back.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: A witness observed a child in care being restrained in the prone position for 1-2 minutes.


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

raw_content: There is not a thermometer in the freezer.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

Correction Narrative:
A child in care was denied food until the child completed the assigned chore.

A face-to- face interview was conducted with victim. Victim states that himself nor any other child in care have been denied food for any reason.


summary: 748.2953(a) - Evaluation-Quarterly, operation must collect, document, & review aggregate numbers of emergency behavior interventions by type of intervention

raw_content: The operation has not completed their quarterly EBI report.

Correction Narrative: The operation has come into compliance with this standard.


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

raw_content: Bathroom cleaner was found in an unlocked cabinet.


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

raw_content: A child was on an unauthorized absence, and it was reported more than 6 hours from when the absence was discovered.

Correction Narrative: On 1/28/25, the operation provided a written correction plan stating Serious Incident Policies and Procedures were reviewed with all staff in a meeting on 12/11/24.  This measure to prevent recurrence brings this standard into compliance.


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: The Medication record does not reflect and accurate count of the medication dispensed to children in care.


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: In review of a child's file, there is no documentation that the child's rights were reviewed with the child.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: The operation does not have daily indoor and outdoor recreational activities for the children to participate in.


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

raw_content: Multiple child's medications records show that they children are not getting medications as prescribed.


summary: 748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record

raw_content: Multiple children have medications that do not have a medication log/ record.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: There were no paper in the bathrooms.

Deficiency Narrative: There were no paper in the bathrooms.


summary: 748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard

raw_content: The bedrail on the top bunk is detached from the bedframe.


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

raw_content: One of the dressers in a child's bedrooms has nails sticking out of the insides and the bed has nails sticking out on the side.


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

raw_content: Children in care are is not receiving their medication as prescribed due to medication running out in addition to a change in the script.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: During the walk through, the bedroom windows do not have coverings.


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

raw_content: In the backyard of the operation the brick wall is falling apart, there is a line protruding out of the ground, and the gutter are cluttered.


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

raw_content: Medication records show that medications have been administered but has not been recording on the medication logs.


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: A child in care was choked and punched by a staff member

Correction Narrative: The operation has come into compliance with this standard


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: Based off the information obtained during the investigation, there was sufficient evidence to support that abuse occurred at the operation.


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: The child's arms were place behind him during restraint.


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: A child in care was restrained in a prone position.


summary: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child

raw_content: During the course of the investigation, it was determined that a caregiver used prohibited punishment to discipline a child.


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

raw_content: During the course of the investigation, it was determined that staff were below the required ratio during at least 30 minutes.


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

raw_content: During the course of the investigation it was determined that a caregiver allowed a child to discipline another child.


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 course of the investigation it was determined that a caregiver was not aware of a child's past behaviors and did not provide the level of supervision needed to ensure child safety.


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: During the inspection it was found that one staff record reviewed was missing the notarized Licensing Affidavit for Applicants for Employment form

Correction Narrative: The administrator sent proof of the notarized Licensing Affidavit for Applicants for Employment form


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

raw_content: During the inspection it was found that a staff record was missing documentation of a TB skin test

Correction Narrative: The administrator sent proof of the staff member's TB skin test


summary: 748.2855(b) - EBI Documentation-Supervisors of caregivers involved in EBI must document review of the intervention within 72 hours of the incident

raw_content: Four of Four EBI records reviewed did not have staff debriefing completed in the EBI reports.


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

raw_content: During the walk through it was observed that the closets had clothing hanging rods that were not properly secured and could be removed and potentially used as a weapon. Additionally, a bathroom sink was observed to be stained with red hair dye.

Correction Narrative: The administrator sent proof of the removal of the clothing rods and repairs made at the operation


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

raw_content: The operation was not clean there were insects and trash on the floor throughout the operation. It was not in good repair due to holes in the walls downstairs, and a shower knob falling off upon turning it as well as a storage doorknob falling off.


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: During the inspection two of seven staff records reviewed did not have adequate proof of a high school diploma or GED


summary: 748.453(a)(2) - Unauthorized Absence  Annual summary log must include time and date absence was discovered

raw_content: The annual summary log was observed to not have the time and date the absence was discovered or how long the child was away from the operation.


summary: 748.363(11) - Personnel records-Include record of training and training hours

raw_content: In 2 out of 8 files reviewed there was no training record available outlining the training hours.


Deficiency Narrative: The operation was not clean there were insects and trash on the floor throughout the operation. It was not in good repair due to holes in the walls downstairs, and a shower knob falling off upon turning it as well as a storage doorknob falling off.


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

raw_content: The operation was observed to have insects such as roaches and gnats throughout the first floor in the children's restroom and in the pantry.


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

raw_content: There is no indication in the treatment director's file that they have any experience providing treatment services for children with an emotional disorder, including one year in a residential setting. Also, the position requirements in the job description states that it is 2 years of relevant experience working with youth.


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

raw_content: During the inspection, personnel records reviewed contained the following issues the date of hire on the staff list was not accurate. A job description was inaccurate regarding the requirements for the position and mentioned agency homes which not applicable. A different agency's name was used in the treatment services policy.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: All children's bathrooms were observed to not have anything available to dry their hands with.


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

raw_content: 1 out of 8 files reviewed did not include a notarized Licensing Affidavit for applicants for Employment form.


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

raw_content: In 1 out of 8 files there was no job description for the treatment specialist. In a different file there was an inaccurate job description. It was for a caregiver however this staff is listed as the house supervisor on the staff list roster.


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

raw_content: A caregiver left another caregiver out of ratio with 7 youth in care when they left the operation in an attempt to locate 2 residents on AWOL.

Correction Narrative: During a discussion with the administrator during inspection #3967132, a mandatory staff meeting was held 9/2 regarding runaway policies and procedures.


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

raw_content: During the review of this investigation, it was found that a caregiver used a prohibited restraint on a child in care. The caregiver admitted to holding the child down with his hands on the childs chest for ten minutes. During the administration the child stated that he could not breathe, and this heard by another child who witnessed the incident.

Correction Narrative: Interviews were conducted with children in care regarding restraints with children reporting that they have not seen further restraints. During the interview with the administrator, Ms. Markena Kelley has stated that refresher training for CPI will be given again in mid-August. All staff will begin a three part training series 8/12/2023 covering the following topics: minimum standards overview, positive interactions and common diagnoses in DFPS youth. On July 30th all staff will be reoriented on child's rights.


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

raw_content: Service Plans that indicated a child having high risk behaviors did not include a plan that would minimize the risk of harm to children in care.


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

raw_content: Service Plans for children involved in the investigation did not have specific and detailed instructions about the level of supervision for staff to properly supervise the children who needed more attention.


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 Administrator implemented a plan which did not properly address the level of supervision needed to address the high risk behaviors some children in care were having.


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

raw_content: During the investigation it was found that a staff member used excessive physical force and slapped a child in care, putting them at risk for physical injury.

Correction Narrative: Interviews were conducted with children in care regarding restraints with children reporting that they have not seen further restraints. During the interview with the administrator, Ms. Markena Kelley has stated that refresher training for CPI will be given again in mid-August. All staff will begin a three part training series 8/12/2023 covering the following topics: minimum standards overview, positive interactions and common diagnoses in DFPS  youth. On July 30th all staff will be reoriented on child's rights. The staff member involved in this investigation was terminated.


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

raw_content: During the investigation it was found that a staff member used profane language to threaten a child in care

Correction Narrative: Interviews were conducted with children in care regarding restraints. During the interview with the administrator, Ms. Markena Kelley has stated that refresher training for CPI will be given again in mid-August. All staff will begin a three part training series 8/12/2023 covering the following topics: minimum standards overview, positive interactions and common diagnoses in DFPS  youth. On July 30th all staff will be reoriented on child's rights.


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: During the investigation it was found that a staff member hit a child in care on the back of the head.


summary: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

raw_content: During the investigation it was found that a staff member improperly restrained a child in care by holding the child around the neck with the child's hands behind their back


summary: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

raw_content: It was observed that the downstairs fire extinguisher in the kitchen area had not had an annually inspection.

Correction Narrative: The fire extinguisher observed in the kitchen on 4/24/2023 has been serviced and retagged as of 4/26/2023 to bring us in compliance with the 748.3117(a) deficiency reported.


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

raw_content: It was found that a staff member did a restraint in a non-emergency situation.

Correction Narrative: All staff are being retrained in EBI on 3-19-23 by Brittani Royston from Klien ISD behavioral specialist.


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

raw_content: It was found that a staff used a restraint as a disciplinary example for another resident in care.

Correction Narrative: Staff member was taken off the schedule for 2 weeks and went through judgment training with Administrator Markena Kelly upon return.


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 had never validated their people list. The operation received their permit on 1/31/22.


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

raw_content: During the inspection; 2 out of the 14 beds were observed to have missing wood along with a nail showing and bed missing steps for a child to access the top bunk.The children bathroom located downstairs is not properly flushing, calming room missing has hole in the wall, and the splashguard located in the child's upstairs shower is detached.  A storage closet was observed unsecured located in a child's bedroom.

Correction Narrative: The operation provided documentation via email of photographs of the beds, calming room, splashguard, storage closet unsecured in child's bedroom,  and video of the toilet properly flushing.


summary: 748.1101(b)(3)(J) - Children's rights-The right to personal space in the child's bedroom to store child's clothes and belongings

raw_content: During the inspection; an observation of  the children bedroom's did not have area to store clothes and belongings.

Correction Narrative: The operation provided documentation via email of photographs of the children bedrooms having the ability to store there belongings .


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

raw_content: During the inspection; an observation of the left rear tire pressure was low and passenger side view mirror missing bottom glass.

Correction Narrative: The operation provided documentation and photographs of safe operating condition of the vehicle. The operation ensured the tire pressure and passenger side mirror was installed.


facility_name: Family Link Treatment Services, Inc.

summary: 748.1337(a) - Initial Service Plan-Base on needs identified in admission assessment; justify delay in addressing needs if service planning team prioritizes goals

raw_content: During the review of a child's files, the initial service plan was not in the child's file.

Correction Narrative:
An email was sent to the inspector on 12/18/25 stating The Legacy Ranch Administrator & Supervisor had a meeting with all Case Managers on 12/10/2025 to go over Compliance. The meeting addressed having all documents completed and in the Extended Reach file by the state-required deadlines.
The Legacy Ranch Administrator & Supervisor will work with the Case Managers to ensure that documentation is completed and in the file. They will help the Case Managers prioritize tasks to ensure documentation is complete and deadlines are met. Sign-in sheet was provided.


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

raw_content: Staff background check was not inactivated timely.