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

Deficiency Narrative: It was observed by the RCCI Inspector that the operation does not have a window with properly fitted and secure screens.


state: TX

facility_name: Trinity Home of Faith 1, Inc.

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

raw_content: In reviewing Backgrounds it was found a current Caregiver does not have an active background check as of 6/22/23 and the People List was validated 9/5/23.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: Reviewed the Online Background Check and the facility had come into compliance with the background.


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

raw_content: 6 out of 7 people interviewed stated staff did not attempt to de-escalate the child which triggered the other children resulting in the incident.

Correction Narrative:
3/9/23 Inspection was conducted and three children were interviewed. All three reporting staff intervene and de-escalate situations as they are occurring. The operation reviewed the deficiency with staff and discussed de-escalation. Additionally the operation reports they have more than one staff on duty when the acuity of the milieu calls for it.

2/28/2023 Email received stating, the Compliance Manager will meet with staff to go over de-escalation techniques as it relates to children in care. Emphasis on knowing the triggers of children.


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

raw_content: All persons interviewed but one verified the victim was left alone at some point while upset and was able to try and self-harm. Staff verified the child was on a 1:1 ratio. It was also verified there was only one staff with all of the girls for most of the shift.

Correction Narrative: No children in care were on a Safety Plan at the time of the inspection.


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

raw_content: In reviewing the 72 Hour/Admission Assessment completed on the day the child was placed, there was no documentation of a Safety Plan put into place and the child had a history of self-harm and suicide ideation.

Standard Risk Level: Medium

Correction Narrative: RCCR Inspector Marnie Layton Reviewed a Child's Chart on 3/30/23 with High Risk Behaviors. A Safety Plan was in place.


summary: 748.863(a)(2) - If EBI not allowed, caregivers for childcare prog. or treat. svc must have 8hrs EBI. 4 before counted in ratio, rest w/in 90 days.

raw_content: A caregiver did not have the required number of hours for emergency behavior intervention before they were being counted in ratio.

Category: Training and Professional Development

Standard Risk Level: Medium High

Correction Narrative: Per email from the operation, the compliance manager will ensure staff are receiving the required number of training hours before being counted in the staff to child ratio


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

raw_content: One child's file did not have specific information regarding the supervision required for a child in care.

Category: Admission, Service Planning, Discharge

Correction Narrative: Per email from the operation, the case manager will ensure each child's level of supervision is clearly identified in the child's service plan and is passed on to the caregivers.


summary: 748.1271(6) - Emergency Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement

raw_content: Review of the Preliminary and Initial Service Plan showed the victims had High Risk Behaviors and no Safety Plan was put into place.

Correction Narrative: Received email from the Program Coordinator stating the Administrator will ensure the Service Plans have the required information and caregivers are able to view it and follow the Safety Plan as required.


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

raw_content: Review of the  Preliminary paperwork stated the victims should be observed every 10 minutes and this was not followed.

Correction Narrative: Received email from the Program Coordinator stating the Administrator will review the Preliminary Service Plan when completed and ensure caregivers are told of a child's specific supervision requirements.


summary: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

raw_content: In reviewing the Service Plan for the victim it was found the child was to be in eyesight while awake and was allowed to go to their room unsupervised to cool down which allowed time to leave the facility through the window.

Standard Risk Level: Medium Low

Correction Narrative: Received email from the Program Coordinator stating going forward the Administrator will discuss with all staff the supervision requirements for each child once the Service Plans are completed.


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

raw_content: A child in care ran away from the operation when allowed to be outside without supervision while making a phone call. The child had only been at the operation for a couple of days prior to the incident and had a history of running away prior to being admitted. The child was also identified as possibly being a human trafficking victim.

Correction Narrative:
The Compliance Manager will
Inservice Staff in regard to
reading the child's Service
Plan, Admission Assessment,
and Common Application
when a child is admitted.
As well as passing on
information shift to shift.


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

raw_content: Based on preponderance it is found that a caregiver yelled at children in care.

Correction Narrative: The Compliance Manager will train staff in regard to compassion fatigue, trauma informed care, and communication with troubled youth. The facility will provide proof of completion to RCCR.


raw_content: Multiple children in care stated that staff yell at them, when they're upset, trying to get their attention and/or being told what to do or not do.

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

Correction Narrative:
The Compliance Manager will In-service Staff in regard to compassion fatigue, trauma
informed care, and communication with troubled
youth.


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

raw_content: It was determined a child's treatment plan was not followed when they were allowed to be outdoors without staff supervision.

Correction Narrative:
Sup Leon spoke with Ms Cartwright and Ms Dugay regarding what the OP did to come into compliance with the issued citation. Ms. Dugay stated that she told each of her staff to not allow the children outside without a staff member being present. Ms Cartwright informed that the service plan says that the staff have to conduct 10 min checks in order to follow the service plans and those can be window checks because all it says is supervised, but their policy says that staff are allowed to just do visual checks. She stated that she will look at the OP's policy to determine a method of coming into compliance and will put it in writing for RC.
Ms Cartwright sent an email to Sup Leon with the following:
The CaseManager will complete and execute Service Plans in detail  while including the the level of supervision when using Normalcy Activities, as this could be different from the policy that states the child will be "supervised every 10 minutes".


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: A child in care did not complete their baseline TB test while in care at the facility.

Correction Narrative: One of the administrators will audit children's files monthly to ensure TB tests are filed in the child's file. They will follow up with staff to ensure they transport children back to the medical facility to have their TB tests read.  The appointment will be logged on the calendar of events to ensure this is completed.


facility_name: Miracal's Place

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: Licensing was not informed within the proper time frame when law enforcement responded to the operation.

Correction Narrative:
RCCR inspector received compliance from operation on 2/20/26.
The operation maintains a mandatory Serious Incident Reporting Protocol requiring that all Serious Incidents are reported within 24 hours of discovery, in accordance with DFPS Minimum Standards, RCC Requirement 1411, and DFPS Contract Terms. All Serious Incidents must be reported to the following entities: DFPS Statewide Intake (SWI), Residential Contract Manager (RCM); Assigned DFPS Caseworker, Caseworkers Supervisory Chain of Command. Staff are required to complete all notifications promptly and ensure accurate documentation of each report and notification within the 24-hour timeframe. The operations procedures for reporting are noted on the corrective action plan found in the document library.


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

raw_content: Training records for active employees were not available to review at the operation.

Correction Narrative:
Reason for Non-Compliance:
Some personnel documents were missing, outdated, or not stored on-site in the central filing system. Staffing turnover and incomplete file audits contributed to the deficiency.
Corrective Actions:
1.Miracals Place will conduct a Full Personnel File Audit
-HR will conduct a complete audit of all personnel files to identify any missing documents (e.g., drivers license, CPR/FA, TB, training certificates, orientation, job descriptions).
-All missing documents will be collected and added within 7 business days.

2. Miracals Place will be sure to conduct a Personnel File Checklist Implementation
-Each file will include a standardized checklist verifying contents required by minimum standards.

3. Miracals Place will ensure a secure On-Site File System Setup
-All active personnel records will be stored onsite in a centralized, locked cabinet or digital secure folder accessible for Licensing review.

4. Miracals Place will implement a New Hire Checklist Procedure
-HR will implement a New Hire File Completion Form to ensure all required documents are received before the staff member is scheduled to begin work.

Prevention Strategy:
Quarterly personnel record audits will be conducted and documented. HR will track expiration-sensitive documents (drivers license, CPR/FA, medical records) using automated reminders.


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

raw_content: Requested documentation to complete an inspection was not available to Licensing upon request.

Correction Narrative:
Reason for Non-Compliance:
Some requested records were not immediately accessible during the Licensing visit due to decentralized storage and staff uncertainty about file locations.

Corrective Actions:
1. Miracals Place will create a Central Records Access System to ensure the following:
-All active personnel, child, and operational records will be stored in a clearly designated on-site location or secure digital platform with Licensing-compatible access.

2. Miracals Place will be sure to implement Licensing File Request Protocol
-A written protocol will be implemented detailing how staff respond to Licensing requests, including response timelines and staff roles.

3. Miracals Place will ensure Staff Training on Licensing Readiness is properly executed:
-Mandatory training will be conducted for all administrative and supervisory staff on record accessibility, Licensing expectations, and retrieval procedures.

4. Miracals Place will improve our Labeling and Organization system
-All file cabinets, folders, digital drives, and binders will be labeled, indexed, and organized by record type to ensure immediate access.

Prevention Strategy:
A monthly Licensing Readiness Check will be conducted by the Administrator or designee to ensure all records remain organized, updated, and immediately accessible.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: Records reviewed show an active staff did not renew annual trainings timely.

Correction Narrative:
Reason for Non-Compliance:
A review determined that annual training for some staff was not completed within the required rolling 12-month training cycle. Contributing factors included inconsistent tracking methods and lack of automated alerts.

Corrective Actions:
1.Miracals Place will implement a Centralized Digital Training Tracker
-A digital spreadsheet or HR system will be used to track all caregiver annual training requirements, including due dates and completion dates.
-Responsible: Training Coordinator / HR.

2.Miracals Place will create an Automated Monthly Training Compliance Report
-HR will generate a monthly report listing staff whose training is due within 60, 30, and 15 days.
-Supervisors will receive this report and ensure completion.

3.Miracals Place will conduct an immediate Remediation for Impacted Staff
-Any staff with overdue annual trainings will complete required courses within 10 business days.


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

raw_content: Multiple medication records were reviewed for children  in care. Medication errors were not documented until several months after the errors occurred.

Correction Narrative:
Inspection #4061552

Immediate Corrective Action Taken:
	Affected medication logs were corrected retroactively.
	In-service training will be scheduled effective immediately to all direct care staff about the two-hour requirement.
	Medication documentation responsibilities were revisited and reiterated to staff.
Preventive Measures Going Forward:
	Clear signage has been posted in medication area(s) reminding staff of the 2-hour requirement.
	As of 06/01/2025, all staff must document within 15 minutes of administration to build in a buffer.
	Spot-checks by Case Manager and or LCCA will occur daily during high-risk times (mornings and evenings).
	Staff non-compliance will be addressed in supervision meetings with progressive discipline.
Responsible Person(s): Case Manager, (Laquinta Banks); LCCA (Nichole Jackson)
Monitoring: Daily spot-checks started 06/03/2025
Date of Full Compliance: 06/03/2025


raw_content: A required annual training taken by staff on November 15, 2023 was not  completed in a subsequent 12-month period. Training was not completed again until April 7, 2025.

Standard Number / Description: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

Correction Narrative:
Immediate Corrective Action Taken:
	On 05/30/2025, a full audit of all staff training records was completed.
	All overdue trainings are being scheduled and will be completed in a timely manner and or no later than 6/12/2025.
Preventive Measures Going Forward:
	A digital training tracker will be created in Excel and integrated with calendar alerts.
	Staff will now receive automated email reminders at 60, 30, and 7 days prior to the 12-month training deadline.
	A monthly HR report will be reviewed by the Program Director/Administer to flag upcoming due dates and overdue items.
	A Policy revision will take place by 06/30/2025 to require written disciplinary action for training overdue more than 30 days.
Responsible Person(s): Case Manager, (Laquinta Banks); LCCA (Nichole Jackson)
Monitoring: Monthly training audits will begin July 1, 2025
Date of Full Compliance: 06/12/2025.


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: Medication directives changed to administer three times a day instead of two times a day. For dates 12/5-12/10, this medication was given twice a day instead of three times.

Correction Narrative:
completed in Follow up 4061552

Immediate Corrective Action Taken:
	The affected child's MAR was corrected on 12/11/2024.
	A medication error report was submitted and reviewed by the Program's LCCA and parties of interest.
	Staff involved were retrained on verifying MARs against current prescriptions.
Preventive Measures Going Forward:
	Effective immediately, all updated prescriptions must be double-verified and documented by both the medication designee, a supervisor, Case Manager, and or LCCA.
	The 4526 form, will be properly implemented and shared with parties of interest within 24 hours.
	Bi-weekly audits of MARs will be conducted by the Case Manager, LCCA, and or designee.
	Quarterly med administration refresher training will now be mandatory.
Responsible Person(s): Case Manager, (Laquinta Banks); LCCA (Nichole Jackson)
Monitoring: MED Logs every Mon, Wed, and Fri as well as Bi-weekly audits begin 06/10/2025
Date of Full Compliance: 06/03/2025.


summary: 748.1381(1) - Service Plan Review-If child not receiving treatment services, review at least 180 days from date of last service plan

raw_content: Service plans were reviewed. Three out of six service plans were not completed in a timely manner.

Correction Narrative:
Immediate Corrective Action Taken:
	All overdue service plans were updated and reviewed as of 05/30/2025.
	A tracking system will be utilized to include separate timelines for non-treatment youth.
Preventive Measures Going Forward:
	A new tracking calendar with automated alerts (120, 150, and 180-day marks) will be implemented on or by 07/01/2025.
	Service plan deadlines are now reviewed weekly or bi-weekly during the case management staff meeting depending on the census.
	Designee sign-off is required for all service plans to verify timeliness before submission.
Responsible Person(s): Case Manager, (Laquinta Banks); LCCA (Nichole Jackson)
Monitoring: Weekly/Bi-Weekly service plan report review begins 06/10/2025
Date of Full Compliance: 05/30/2025.


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 not reported to the hotline that there was an allegation of an employee was sleeping during her night shift.

Correction Narrative:
The operation responded: It is the responsibility of Miracal's Place to ensure that ALL serious incident reports are reported to the proper partied such as licensing, caseworkers, license reps and those that meet the approval.

Moving forward Miracal's Place will be sure to report ALL serious incidents as required.


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

Deficiency Narrative: It was not reported to the hotline that there was an allegation of an employee was sleeping during her night shift.


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

raw_content: During the walkthrough the blinds in the dinning common area were observed not on the middle windowpane and were on the floor. The blinds in the bedrooms were not in good repair.

Category: Physical Site


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: During the inspection 3 out of 4 staff files viewed employment history check results  were not present in staff files.

Category: Personnel


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

raw_content: During the inspection while viewing staff files 2 out of the 4 files viewed did not contain reference checks in the staff files.


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

raw_content: During the inspection it was observed that the toilet in the bathroom upstairs is broken. The seat is not properly attached to the base of the toilet.


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

raw_content: During the inspection viewing the medication log four out of four child records did not include the correct remaining count on the medication log.

Category: Medication


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

raw_content: During the inspection while viewing staff files 1 out of 4 files viewed did not contain results of the employment history check.


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

raw_content: During the inspection while viewing staff files a job description was missing, no verification of background check, no hire date were missing from staff file.

Category: Reports and Record Keeping


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: During the inspection while reviewing the unauthorized log it was noted that there was no evaluation of absences in the past 6 months at the operation.


summary: 748.363(12) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months.

raw_content: During the inspection while reviewing staff files 2 out of the 4 files viewed contained expired driver's license.


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

raw_content: During the inspection while viewing the medication log it was observed that two out of four child records reviewed did not contain documentation of PRN medications administered.


summary: 748.461(4) - Unauthorized Absence Triggered Review must include a written plan to reduce unauthorized absences of child, which must be in childs record

raw_content: During the inspection while viewing the unauthorized absense log it was observed that the log did not contain a triggered review after a child in care ran away three times.


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

raw_content: During the inspection while viewing the unauthorized log it does not include the date and time the absence was discovered.


summary: 748.363(14) - Personnel records - Include any documentation of the person's performance with the operation.

raw_content: During the inspection when reviewing staff files, none of the files contained documentation of staff performance


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 observed when reviewing staff files that 2 out of 4 records viewed form 2985 is not signed by the employee although it was notarized. Form 2912 is also missing


summary: 748.1101(b)(3)(C) - Children's rights-Adhere to the child's rights to have religious needs met

raw_content: A child in care was not having their religious needs met and was denied going to church due to the operation's staffing.

Correction Narrative: Interviews were conducted with youth in care from the operation. The youth interviewed stated they are not being denied the right to attend church services and have their religious needs met.


summary: 748.125(d)(6) - Suicide Screening- Must be documented.

raw_content: There was no suicide screening conducted.

Correction Narrative: The operation's administrator provided an email which included the operation's updated supervision policy to include the need for a suicide screening. The email also included a sample suicide screening the operation anticipates utilizing going forward.


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

raw_content: Three out of three youth files reviewed did not include documentation showing a 2 week advance notice to parents regarding the youth's service plan meetings.

Standard Risk Level: Low

Correction Narrative: An email was received from the operation which included a corrective action plan that indicated the operation will create and maintain a calendar of each resident's service plan due dates to be able to schedule the team meeting at maximum 2 weeks in advance. The email also included a copy of the calendar template.


summary: 748.705(b)(7) - Reasonable & prudent parent standard-must consider the surrounding circumstances, hazards, and risks of the activity

raw_content: A caregiver didn't demonstrate prudent judgement when they did not report a sighting of a youth in care on AWOL status that later was placed in a hazardous situation.

Correction Narrative:
Follow up interviews were conducted with youth in care to ensure the staff involved in the incident is no longer working at the operation and the same allegations aren't occurring. No concerns were noted. Interviews documented in Chronology.

During exit interview on April 9, 2024, the administrator indicated the staff involved in the incident is no longer employed at the operation. She also indicated staff have been retrained on reporting and using prudent judgement.


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

raw_content: This standard was found deficient as a result of a DFPS investigation.


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

raw_content: Upon reviewing the emergency drill log, it was found that the drill dated 5/6/2023 was over the 3-minute allotted time.

Category: Safety and Emergency Practices

Correction Narrative: An email was received from the operation's administrator, Nichole Scott, that included the fire drill log. On the log was a drill indicated to have been performed on November 10, 2023 that lasted for under the 3 minutes as required.


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

raw_content: During the physical walkthrough the freezer was observed to not have a thermometer.

Correction Narrative: An email was received from the operation's administrator, Nichole Scott, that included a picture of the new thermometer inside the freezer at the operation.


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: A caregiver engaged in a physical altercation with a youth in care.

Correction Narrative:
A phone call was made to the operation's administrator to inform of the citations. The administrator informed that the employee involved is no longer employed by the operation. Later in the day, the administrator notified all parents of the current youth in care as required evidenced by the Licensing Rep being CC'd on the email notification.

Follow up interviews conducted with youth in care on April 12, 2024. Documented in Chronology.


raw_content: A youth in care was found to be physically abused by a caregiver.

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


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

raw_content: An incident occurred and an incident report was completed regarding suicide which included making verbal threats and a physical attempt on 3/26/23 however it was not reported to Licensing until 3/27/23 when the child was actually hospitalized.


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

raw_content: During the inspection, a fence in the backyard was observed to have two loose boards with multiple nails exposed creating a risk of harm. Two spots on the kitchen floor were also observed to have missing wooden floorboards. One electrical wall plug on the kitchen island was also observed to be loose and hanging off the wall.

Correction Narrative: The operation fixed all outside fence boards and replaced the entire flooring on the inside of the home.


summary: 748.945(2) - Annual Training-Caregiver that administers psychotropic medication must receive annual psychotropic medication training every 12 months

raw_content: One caregiver who administers psychotropic medication does not have an updated training.

Correction Narrative: An email was received from the operation including a corrective action plan that indicated the operation will be responsible for ensuring staff keep their trainings up to date. A copy of the employee's training recently taken was also provided as verification.


summary: 748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification

raw_content: One staff member file reviewed had an expired CPR/First Aid training.

Correction Narrative: An email was received from the operation including a corrective action plan that indicated the operation will be responsible for ensuring staff keep their trainings up to date. A copy of the employee's current CPR card was also provided as verification the training has been taken and updated.


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: One out of four youth records reviewed did not have the medical consent form signed.

Correction Narrative: An email was received from the operation with the corrected form attached.


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

raw_content: Three of 5 children stated staff was used. A/N investigator confirmed this during an investigation. Three of 5 children indicated favoritism. Two of 5 children stated belittling language was present.

Correction Narrative: An email was received from the operation's administrator including a corrective action plan that indicated staff will be refreshed on de-escalation techniques and trauma-informed care to prevent the use of profanity. The plan also indicated any staff that doesn't adhere to the operation's policy will be reprimanded accordingly.


facility_name: Stadium  Shelter

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

raw_content: A staff did not use prudent judgement when supervising the children in public on outings, which allowed them to elope.

Correction Narrative:
The following corrections were made to ensure the operation is in compliance: All direct care staff will receive immediate refresher training on the Reasonable and Prudent Parent Standard and elopement prevention/intervention procedures by 08/14/2025.

Enhanced Outing Protocol: The outing risk assessment form will be updated to include a "High Risk for Elopement" flag, ensuring additional preventative measures (eg. buddy system, extra staff assignment) for residents with known elopement history.

Increased staffing on Outings: For any youth identified as a potential flight risk, outings will include at least one additional staff member above the required ratio to provide layered supervision.

Documentation review: Supervisors will review outings plans and post-outing incident reports weekly to identify patterns or areas for procedural improvement.

All corrective actions will be implemented and documented by 08/14/2025.
Inspector verified training roster and certificates 08/28/2025.


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

raw_content: It was noted that a caregiver had a TB test from 2013 that read positive. There was no chest exam to observe.

Correction Narrative: On 02/28/2023 A copy of the employees TB Xray results was emailed to the inspector. In addition, three TA that were given to the facility were corrected and sent by email to the inspector. All corrected will be uploaded into the ccl storage.


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

raw_content: A staff did not use prudent judgement when accessing her private social media account on a device meant for the resident's Zoom calls, which allowed them access to inappropriate content.

Correction Narrative: Per the Administrator, Stadium Shelter terminated the staff immediately once poor judgement was utilized in the usage of a device for residents. A letter of separation was received dated 2/6/23. BGC is Inactive as of 2/7/23.


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

raw_content: Two children expressed that a staff grabbed a child and got in their face because the child would not comply.

Correction Narrative: The administrator will also provide the necessary training to each staff member. The training will be conducted on 01/21/23 and a posttest with a 75% or higher.


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

raw_content: Three children in care voiced a staff not intervening in an incident with another staff and a child.


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

raw_content: Children in care expressed that staff yell at them when upset.


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

raw_content: Medication administration is being signed by administrator and not the staff who is administering the medication.

Correction Narrative: Operation emailed me the medication administration records where staff administering the medication are signing the sheet.


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

raw_content: Two meat packages were left uncovered in the freezer.

Corrected at Inspection: Yes


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

raw_content: During the inspection three out of five child records reviewed included predated and signed weekly preliminary plan forms, as well as monthly extension forms.

Correction Narrative: The Administrator and Case Manager will ensure that the required extensions will be added to the files during the week and month it is due.


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

raw_content: The operation did not have an assigned treatment director working full time at the time of inspection.

Correction Narrative: Stadium Shelter has hired a treatment director. The treatment director has a valid background check and will begin job duties as scheduled.


summary: 748.3273(6) - First Aid Kits-Each one must contain scissors

raw_content: During the inspection three first aid kits were observed. One first aid kit was missing scissors. Another first aid kit was missing scissors, tweezers and a thermometer. The first aid kit in the vehicle was also missing scissors, tweezers and a thermometer.


summary: 748.865 - Pre-Service Training-Orientation training must be separate from pre-service training

raw_content: 4 out of 4 employee files reviewed included the required emergency practices pre-service training with the orientation training hours.

Correction Narrative: The Administrator will ensure that the required emergency practices training will be included in the pre-service training instead of the orientation training.


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

raw_content: The faucet in the bathroom of one of the bedrooms was found to be loose and able to be lifted.


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: Tv stand in the common area was observed to have a broken piece.

Correction Narrative: During inspection it was observed all furniture to be in good standing.


summary: 748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit

raw_content: 1 fire extinguisher was observed to be not in good standing as the needle was in the red.

Correction Narrative: A picture of a new fire extinguisher was received via email. This new fire extinguisher is to replace the one found to be out of service during the team inspection. Compliance has been met.


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

raw_content: 1 of  the 4 bedrooms at the agency was not lighted. The room isn't occupied. A work order was produced for correction.


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

raw_content: The emergency and evacuation plan is not posted in the living quarters used by children where it is visible.

Correction Narrative: During inspection it was observed that evacuation plan is posted throughout different parts of the building.


raw_content: 2 of 3 staff interviewed stated that the Childs are not allowed to take their property on AWOL as a facility rule not as a de-escalating skill.

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

Correction Narrative: An email was received that entailed that The administrator will ensure that all staff has proper de-escalation training, as well as, be reminded of the de-escalation policies and procedures. Administration will also inform staff that the purpose of these policies and procedures is to prevent harm to children due to the use of behavior management techniques that inflict physical or emotional pain or discomfort. These prohibited methods of punishment are considered physically, psychologically and/or emotionally abusive including not allowing the child to leave with their personal property if it is not to de-escalate the child.


facility_name: City of Hope Missions, DBA, Hearts-Way Youth Shelter

raw_content: During the inspection, it became evident a staff member was seen by other staff members transporting children despite having told other staff she was over tired.  The staff in question also was discovered to have been making inappropriate comments and engaging in undesired physical contact with the boys.

Correction Narrative: On 11/21/25, The operation submitted corrections indicating the offending staff's employment was terminated prior to the initiation of this investigation.  Staff will continue to be trained regarding appropriate conduct and communication.  Supervisory staff are responsible for reinforcing, coaching, and monitoring staff to ensure compliance.


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

raw_content: During the investigation, it was discerned a staff member used inappropriate language around and toward these children in care.

Correction Narrative: On 11/21/25, The operation submitted corrections indicating the offending staff's employment was terminated prior to the initiation of this investigation.  Staff will continue to be trained regarding boundaries and judgement.  Supervisory staff are responsible for reinforcing, coaching, and monitoring staff tot ensure compliance.


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

raw_content: During the investigation, it was discovered the operation failed to provide a safe environment by placing a child with child sexual aggression history as a roommate to two children with sexual victimization history.

Correction Narrative: On 11/4/25, the operation submitted corrections by email.  Upon discovery of the concern, the children were immediately reassigned to separate rooms to ensure their safety and wellbeing.  Measures taken to prevent recurrence include: The operation has revised their room placement procedures to ensure all Attachment A histories are thoroughly reviewed prior to making room assignments.  A formal review checklist has been implemented to verify all relevant behaviors and histories are considered.  The administrator will oversee all room assignments.  Children identified in this investigation will remain in separate rooms for the duration of their stay.


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

raw_content: During a walk through of the operation, several food items were noted to be expired by several years that were in can goods.


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

raw_content: During the investigation inspection, EBI training certificates were reviewed and four staff members  were delinquent on completing their EBI refresher trainings.

Correction Narrative: On 4/29/2025, the operation's Administrator provided EBI refresher training certificates to verify the four individuals who were lacking the required trainings, had completed the trainings and the operation is in compliance. The Administrator advised, to enhance their compliance with this Plan of Correction, they will implement training for all current staff and new hires in January and July of each year. The Administrator will play a key role in ensuring that all staff members complete this training in a timely manner.


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

raw_content: During the investigation inspection, one child's medication record was not updated within 2 hours of staff administering the medication


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: The operation did not have a copy of the child's tuberculosis screening. The child has been living at the operation for over 40 days.

Correction Narrative: The operation submitted an email stating that they have created a new document for intakes that includes all required documents for the intake. The assistant treatment director will be responsible for ensuring that all documents needed at intake are received and filed in a timely manner. The operation also submitted a copy of the missing TB test that was not in the child file.


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

raw_content: The employee file reviewed did not have a copy of the required reference checks required for employees hired after August 2023

Correction Narrative: A copy of the pre-employment reference check was completed and submitted. The operation also stated that they would be conducting the reference checks as part of their hiring process in the future.


summary: 748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development

raw_content: During the investigation, it was reported by three of the four children interviewed that the food at the operation is molded and expired. One child reported being given snacks in November 2024, that had an expiration date of March and July of 2024. The other two children reported there is molded and expired foods in the refrigerator.  The protocol the staff and administrator report are being utilized to ensure there is no molded or expired foods is conflicting.

Correction Narrative: An unannounced follow up inspection was conducted on December 11, 2024. Inspector observed the food in the refrigerator to be compliant and not expired. Pictures were taken. In addition, the operation provided a checklist for expired food and a daily checklist. Regarding food and portion sizes, the operation offers children the opportunity to enjoy as much as they desire. The operation provides healthy options such as salad, fruit, and water. The operation engages in discussions with the children about the benefits of making healthy choices.


raw_content: One child's record was missing documentation for the morning dose.

Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

Correction Narrative: Administrator is dedicated to ensuring the safety, and well-being of our children. Recognizing the important of medication management, we will provide additional medication training with a strong emphasis on the importance of vigilance and awareness when administering medication to the children, and documenting in a timely manner. All current staff will complete the medication administration training by September 30, 2024.


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

raw_content: During the investigation inspection, there was an open package of sliced cheese and smoked sausages in the refrigerator, uncovered.


raw_content: During the investigation inspection on 8/8/2024 and follow up inspection on 9/5/2024, a childs bed was observed to have a broken slat.

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

Correction Narrative:
On 9/9/2024, the operation's Administrator provided photographs to show the child's bed was repaired.

10/21/2024 - follow up was completed at the operation. The beds were repaired an in good condition. Inspection #


raw_content: It was alleged a caregiver tried to physically fight a child in care.

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

Correction Narrative: A follow up inspection was conducted at the operation on Monday October 21, 2024. On 10/4/2024, the operation's administrator advised the administrator will provide additional training to further enhance the protection of children's health, safety, and well-being. It is our intention that all current staff and new hires receive training on the City of Hope's Policy and Minimum Standards, encompassing supervision requirements for the safety and well-being of children. We will be initiating an Administrative Review to ensure that all necessary steps are taken to address the violations and prevent their recurrence in the future. This review is a vital part of our commitment to continuous improvement and maintaining the highest standards of care.


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: It was alleged a caregiver threatened to have their children fight a child and another caregiver would jokingly threaten to use a 2x4 on children in care.

Correction Narrative: A follow up inspection was conducted at the operation on Monday October 21, 2024. On 10/4/2024, the operation's administrator advised as part of their dedication to the well-being of children, we will ensure that all current staff and new hires receive training on the City of Hope's Policy and Minimum Standards, with a significant focus on the Child's Rights, particularly 'The right to be free from abuse, neglect, and exploitation. We will be initiating an Administrative Review to ensure that all necessary steps are taken to address the violations and prevent their recurrence in the future. This review is a vital part of our commitment to continuous improvement and maintaining the highest standards of care.


summary: 748.1117 - Documentation of searches-Caregiver documents searches in the child's record

raw_content: There are allegations caregivers were conducting bedroom searches but those searches were not documented.

Correction Narrative: A follow up inspection was conducted at the operation on Monday October 21, 2024. On 10/4/2024, the operation's administrator advised the operation will ensure that all current staff and new hires receive continual training on proper documentation and room search procedures. We will be initiating an Administrative Review to ensure that all necessary steps are taken to address the violations and prevent their recurrence in the future. This review is a vital part of our commitment to continuous improvement and maintaining the highest standards of care.


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

raw_content: In the 15-passenger van two of the safety belts are in need of repair.  One does latch but the front cover was missing.  The other does not latch.   These are both seats that would normally be occupied by residents.

Category: Transportation

Correction Narrative: The following information was provided.  The agency is not using the vehicle and is utilizing another vehicle.  The agency daily checks with current vehicles to verify operative compliance.  Staff are provided a vehicle maintenance checklist.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: In two of the records reviewed, there was no signature to indicated two professionals were included in the service plan meeting or team.

Correction Narrative: Recognizing the pivotal role of caregivers in the service planning process, we will proactively involve at least one current caregiver in the Initial Service Plan team. We have established a system:  the administrator or designee will send a Zoom link for the meeting two weeks in advance. This will allow ample time for the caregiver to attend the conference. If necessary, we are prepared to make adjustments to the date and time to accommodate the caregiver's schedule. Their unique perspective from spending significant time with the child is invaluable in developing an appropriate plan, and we deeply appreciate their contribution.


summary: 748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers

raw_content: In two of the plans reviewed there was no signature provided to show that at least on caregiver was present and participated in the service plan meeting..

Correction Narrative: ): Acknowledging the crucial role of professionals with the appropriate expertise in the service planning process for children receiving treatment services, we will implement a systematic invitation process. This will entail the administrator or designee sending out Zoom link invites to all relevant professionals and adding the child's primary caseworker, CASA worker, and members in the child's interest to the planning team.


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: The Downstairs boys' bathroom did not have individual hand towels or disposable paper towels at the inspection.


raw_content: There were hamburger buns with mold in the kitchen cabinet.

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


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

raw_content: During the investigation, it was discovered the operation failed to fill a child's prescription medication timely, resulting in the operation failing to administer medication to the child according to the instructions on the label. The cream was prescribed on 2/12/2024 and wasn't filled until 2/28/2024. The written orders were to apply topically daily.

Correction Narrative: On 4/22/2024, the Administrator provided an email stating the Administrator places utmost importance on safely and responsibly administering children's prescription medication. Medication will be administered with strict adherence to instructions or a prescribing healthcare professional's order, ensuring the highest level of safety and care.


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

raw_content: During the investigation it was discovered that a child was permitted to go outside the cabin in an attempt to de-escalate what could have been a physical altercation with another child in care. During that time, the child was able to walk off the premises and allegedly found a pack of marijuana infused gummies, in which he later ingested, became ill, and needed to seek emergency medical care. Due to the circumstances surrounding the child's history with drug use and sexual behaviors and in addition to the CPS Child's Plan of Service, the operation failed to supervise the child adequately.

Correction Narrative: On 4/22/2024, the Administrator provided an email stating the Administrator is deeply committed to ensuring our children's health, safety, and well-being. Additional training will be provided, emphasizing the importance of constant vigilance and awareness of the children in our care. All employees share in this responsibility for the children's supervision, safety, health, and well-being.


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

raw_content: Two of the four residents and all staff interviewed reported outings have been limited since the move to the new location. Two residents reported approximately one outing a week, while one staff stated there has not been any outings in a few weeks.

Correction Narrative: The administrator and the campus supervisor will continue to provide daily indoor and outdoor recreation and other activities appropriate to children's needs, interests, and abilities. Bi-monthly, we will review the recreation calendar and make adjustments if needed due to uncertainty or inclement weather. We will continue providing for children willing to participate outdoors, even if most do not want to participate.


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 at the operation was able to start a fire in nearby wooded area..

Correction Narrative:
The following information was submitted via email on 1/22/24 by the Administrator as a Plan of Correction for the minimum Standard 748.685 (a)(4):
1.	The Administrator will continue to give additional training to protect children's health, safety, and well-being. We will take additional steps to train on the supervision of children, emphasizing the importance of hearing and seeing the children in care at all times.

2.	All our staff will be trained in Pyromania Disorder.

3.	This training will be completed by 01/26/2023; training certificates will be filed in the respective staff HR files.

On 2/1/24 I made an inspection to the operation.  There were no children present at the time of inspection. According to the Adminisstrator the training for staff took place on 1/26/24. The child that was involved has since left the operation.


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

raw_content: During the inspection, I observed that one of the medication logs for the children showed administration of medications without a staff signature or the time of administration for 8 administrations.  Through document review and interviews, I also observed that medications logs were not signed by the staff that administered the medications to the children.

Correction Narrative:
The operation offered the following plan of correction for this standard:

Please find the Plan of Correction for the minimum Standard 748.2151 (c)(6):
1.The Administrator will continue to provide additional training to ensure all employees properly document medication logs for each child and complete them accurately on time.
2. All our staff will be trained to administer the medications; however, we limit only the supervisors to preparing the medication.
3. In-house medication log training will be completed by 08/11/2023; training certificates will be filed in the respective staff HR files.


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

raw_content: Interviews during the investigation indicated that staff members use profane language around the children and in conversation with them.

Correction Narrative: The operation emailed documents showing administration reviewed the discipline policies and minimum standards pertaining to prohibited punishments.


summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: In one of the records reviewed a staff was hired 9/15/22 but did not received the First-aid/CPR Training until 4/13/23.


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

raw_content: During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees fahrenheit.

Correction Narrative:
On 6/13/2023, the administrator provided a plan of correction for minimum standards 748.3443(b)(1) and 748.3443(b)(2):
1.	We changed the thermometer to digital in all the fridges and freezers, so it is easy for all the staff to catch the temperature if there is a discrepancy from the minimum standard required.
2.	We requested the staff not to overload the fridges and freezers, which might affect the temperature, especially during the summer.
3.	We will have staff continue daily the temperature logs.


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

raw_content:
During the investigation inspection, the black
refrigerator in the kitchen had a thermometer that
read 45 degrees fahrenheit, indicating the food in
the refrigerator was not stored at the required 40
degrees fahrenheit.


raw_content: During the investigation inspection, the mini refrigerator in the kitchen had a thermometer that read 50 degrees Fahrenheit, indicating the food in the refrigerator was not stored at the required 40 degrees Fahrenheit.

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

Correction Narrative:
On 5/31/2023, the administrator advised the operation has replaced the thermometers in the freezer and refrigerator. A photograph was provided to verify the thermometers were within range as required in Minimum Standards.

On 6/13/2023, the administrator provided a plan of correction for minimum standards 748.3443(b)(1) and 748.3443(b)(2):
1.	We changed the thermometer to digital in all the fridges and freezers, so it is easy for all the staff to catch the temperature if there is a discrepancy from the minimum standard required.
2.	We requested the staff not to overload the fridges and freezers, which might affect the temperature, especially during the summer.
3.	We will have staff continue daily the temperature logs.


raw_content: During the investigation inspection, the standalone freezer in the kitchen had a thermometer that read 20 degrees Fahrenheit, indicating the food in the freezer was not stored at the required 0 degrees Fahrenheit.

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


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

raw_content: During the inspection, I observed that one resident bed had a damaged box spring with exposed spring and wood through torn fabric,  This box spring was removed during the inspection and the child was relocated to another bed.


raw_content: During the inspection, I observed a refrigerator unit used to store children's food without a thermometer.

Correction Narrative: On 5/12/23, the operation provided photographic evidence that the thermometers were properly installed in the refrigerator unit.  This brings this standard into compliance.


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

raw_content: In reviewing the Serious Incident Report, I observed that the documented time of the incident was incorrect and that several locations requiring the documentation of date and time included the date but no documented time.

Correction Narrative: The operation provided a plan to retrain with a completion date of 6/5/23.  I, Eric Sjerven, updated the compliance date from 5/22/23 to 6/5/23 to reflect this date.  On 6/5/23, the operation provided training certificates for their staff denoting two hours of training in documentation.  This brings this standard into compliance.


summary: 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

raw_content: In reviewing the documentation, I observed that the Serious Incident Report does not include the time that Law Enforcement or the caseworker were notified.


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

raw_content: After reviewing the documentation, I observed that seven out of the seven children's individual service plans reflected a supervision ratio of one caregiver per five children.  These seven children were transported to school at a ratio of seven children to one caregiver.

Correction Narrative:
On 4/6/23, the operation provided a plan to retrain staff in order to ensure future compliance.  On 4/10/23, I requested more specific details with regards to the date the trainings would be completed.  The operation will have training certificates to me by 4/24/23, and I have updated the compliance date from 4/10/23 to 4/24/23 to allow sufficient time to complete the trainings.

On 4/24/23, the operation provided training certificates for their staff in the subjects of Ratio and Transporation standards. This brings this standard into compliance through preventative measures.


summary: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

raw_content: Resident and staff indicated that they have observed a stff member sleep while on duty.

Correction Narrative:
Plan of Correction for minimum standard 748.1013(a) was sent via email from Kui Cogan, Adminstrator on 4/17/23.
a.	We will continue with the current staff, and New Hires will receive retraining on City of Hope's Policy and Minimum Standards and be aware of the supervision requirements for the safety and well-being of children.
b.	We have continued with ongoing Training on 24 hours awake, refresh our current staff. We will submit the Completion of Training Certificates by April 24th, 2023.
c.	We will send a memo to all the staff for Zero-Tolerance Policy for sleep on duty, which would lead to immediate termination.


summary: 748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies

raw_content: One of the four serious incident reports reviewed failed to show that the caregiver attempted to de-escalate with the child before and during the restraint.

Correction Narrative: The operation updated their serious incident reports to include all areas needing to be addressed during and after a restraint.


raw_content: During the inspection it was learned that the person giving the medication to the children was not the person who was signing the medication log.

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

Correction Narrative: The administrator sent a copy of the new medication log that included a space for the staff to sign when they administer the medication.


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

raw_content: During the investigation inspection it was learned that the medication was being administered in a separate container that was not the original container that the medication came in.

Correction Narrative: The administrator sent a email stating that they will now dispense the medication in the medication room by trained staff members.


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

raw_content:
During a review conducted on July 29, 2022, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and
(2)	12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the failure of your operations administrator to ensure compliance include the following:
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

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

Correction Narrative: A HM extension was approved effective 07/30/2022.  In conjunction with this extension, a new a deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 01/30/2023.


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

raw_content: A child in care was denied the right to attend church as a form of discipline.  Although  he had been asked to leave the previous evening,  he had not been banned by the church.

Correction Narrative: Ms. Cogan sent me information that they are having staff review the child rights and they are continuing to have ongoing trainings each week addressing child rights and minimum standards.  A follow-up inspection will be done.


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

raw_content: Due to staff not being aware, one child was put in a choke hold by another child.  As a result, a canceled outing led to another child doing several thousand dollars worth of damage to the operation's property.

Correction Narrative:
An email was sent stating what the correction plan will be for this citation---the Plan of Correction for minimum standard 748.685(a)(5)
1.	All current staff and New Hires will be trained on City of Hope's Policy and be aware of the safety and well-being of children.
2.	We have implemented special Training on Transportation.
   A follow-up inspection will take place within the next week.  Follow up inspection done on 8/30/22 with no issues or concerns.


raw_content: A caregiver used profanity when talking to or about two teenagers in care.

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

Correction Narrative: Ms. Cogan sent me corrections for the profanity that the caregiver had been using. They have a safety plan in place, and she is also on a disciplinary plan - where more inappropriate talk will lead to termination.


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

raw_content: Staff yelling, threatening, cursing and egging on the children. Bouts of frustration and anger towards the kids.

Correction Narrative:
Operation followed these procedures with the staff member.

. City of hope missions policy and procedures was reviwed and s document for discipline response to possiive behaior was signed by staff.

.Staff attended the child abuse and neglect training.

. A disciplinary warning letter was given to the staff member.


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 failed to submit quarterly EBI data timely.

Correction Narrative: The operation entered the EBI data for 1st quarter into CLASS. Data submission deadline will be put on the Heartsway Youth Shelter administrative calendar. It is the intention to submit the data 7 calendar days prior to the deadline. The quality assurance officer will keep a log of all EBIs incurred and the submission of the data. A screenshot of the submission will be taken and kept along with the EBI log.


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

raw_content: A caregiver violated the Operation's policy by taking children in care to unauthorized places (personal residence) without prior permission from the  administration.


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

raw_content: A staff member fell asleep for a few minutes while caring for children in care

Correction Narrative: A discussion was held with this staff regarding the allegations and she has a clear understanding of the necessity to both stay awake and supervise the residents at all time when on duty. This citation has had an administrative review requested based on: The investigator told the staff that a video had been provided to her by the facility management at the start of the interview,  so the staff agreed to the allegations despite not believing them to be true due to intimidation.


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

raw_content: (4) out of (6) children in care were interviewed and reported that they saw one caregiver vaping while inside the facility, on the premises while providing care to children, and in the facility van while transporting children in care.

Correction Narrative: All staff have been informed in writing of the HHSC regulations surrounding the use of Tobacco and Vaping devices. (signature sheet will be on sight for review) An administrative review request has been filed regarding this citation. No smoking signs have been put in the outdoor area in question.


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

raw_content: Freezer reading was 21 instead of 0 degrees.

Correction Narrative:
In correction, the Freezer that was cited is in repair and a deep freezer was
purchased until the freezer is repaired fully. Daily temperature logs were replaced in the kitchen
to monitor temperatures and to ensure temperatures do not fall below the required temperature
to store food and to prevent any food borne illness. If an appliance is in need of repair, food will
be removed and placed in a separate freezer to maintain compliance.


summary: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

raw_content: Two beds did not have pillow cases.  Both were corrected at inspection.


summary: 748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification

raw_content: One staff, whom the operation confirms is in ratio for child care, had a CPR / First Aid expired on 6/25/2021.

Correction Narrative:
CPR/First Aid has been
rescheduled due to a COVID exposure by our then trainer. The new CPR/First aid class will take
place on Wednesday 08.25.21

This will be updated when the training certification is completed and a copy provided.

Training verification provided 8/26/2021.


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

raw_content: There was no protective covering on one child's bed.  Bedroom # 1


summary: 748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities

raw_content: In the Initial Service Plan reviewed there was no signature documented for the person making decisions about the child's participation in childhood activities.  Also there is no documentation where a current caregiver participated in the service planning.  This is listed under a different standard number, but it is being cited underneath this standard.

Correction Narrative:
The following was submitted on 8/17/21 via email from Joy Banks, Administrator:
According to the noted admission assessment, the previous Administrator didn't fully complete the assessment by adding a date. Moving forward, the Administrator will ensure that all signatures are provided and dated to ensure it was completed timely. Although, caregivers are invited to service plan meetings, the Administrator will ensure the service plan is complete on time and will audit service plans upon completion which will ensure the service plan is written and all signatures are captured by caregiver(s) and all that participated.


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

raw_content: In the admission assessment reviewed there was no date documented on the assessment.  Without the date documented it is not clear if the assessment was completed timely.


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

raw_content: During an inspection at the operation it was determined the facility used an online report summary to serve as the serious incident documentation. The summary was missing the time of the incident, age of the child and date of admission, and The treating licensed health-care professionals name, findings, and treatment.

Correction Narrative: At the HM inspection today I was provided with a copy of the revised incident report.  The report meets the requirements and according to the Administrator it is the form that the operation will be using moving forward.


raw_content: Three of the residents beds did not have a matress cover

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

Correction Narrative: Kedrick Pink inspected bed coverings during inspection # 3830103 on 6/24/2021 and found no concerns.


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

raw_content: The administrator used a term with a resident that is not acceptable in polite communication.

Correction Narrative:
THIS EMPLOYEE WAS TERMINATED:

City of Hope Missions Inc. does not approve of such behavior by any staff. As an
employee of COHM, it is imperative that we use the proper treatment policies and procedures in
place to prevent any cruel and unusual punishment. We are here to support each youth and manage
their behaviors appropriately which is reiterated in trainings and daily communication with staff.
All employees are to refrain from using any profane language with anyone especially our youth
that are in our care. The term that was used in response to a youth is completely inappropriate and
doesn't model the behavior that City of Hope Missions Inc. represents at any time. City of Hope
Missions Inc. made the appropriate changes administratively to prevent any of this type of behavior
from occurring further. At anytime if a youth feels uncomfortable, mistreated or their rights are
being violated they are given the opportunity to call the ombudsman or submit a grievance. City
of Hope Missions monitors all grievances and will meet with the youth regarding their grievance
and take the appropriate measures to addressing grievance.


summary: 748.2301(c) - Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed

raw_content: The response a caregiver/administrator chose to use in response to inappropriate child behavior did not teach acceptable behavior or self control but was equally inappropriate.


summary: 748.535(2)(F) - Child-care administrator responsibilities-Ensuring that operation complies with applicable rules of chapter 748 and other applicable rules and laws

raw_content: The administrator did not ensure that the operation complied with 748 standards.

Correction Narrative:
THIS EMPLOYEE WAS TERMINATED:

 City of Hope Missions Inc. does not approve of such behavior by any staff. As an
employee of COHM, it is imperative that we use the proper treatment policies and procedures in
place to prevent any cruel and unusual punishment. We are here to support each youth and manage
their behaviors appropriately which is reiterated in trainings and daily communication with staff.
All employees are to refrain from using any profane language with anyone especially our youth
that are in our care. The term that was used in response to a youth is completely inappropriate and
doesn't model the behavior that City of Hope Missions Inc. represents at any time. City of Hope
Missions Inc. made the appropriate changes administratively to prevent any of this type of behavior
from occurring further. At anytime if a youth feels uncomfortable, mistreated or their rights are
being violated they are given the opportunity to call the ombudsman or submit a grievance. City
of Hope Missions monitors all grievances and will meet with the youth regarding their grievance
and take the appropriate measures to addressing grievance.


summary: 748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment

raw_content: A resident reported and another corroborated that the administrator threatened loss of placement.

Correction Narrative:
Additional follow-up information may be updated once the administrative review process is complete.

On 05/21/2021, the identified Administrator resigned from the operation. This information was verified through an inactive BGC status and in subsequent unannounced inspections.

2/2/22 I spoke with Kui Kuppuswamy-Cogan as a follow-up in reference to this citation while at my HM Inspection on this day.  She indicated that the Administrator who was involved in the situation was terminated for the operation back in May 2021 as a  result of this and other behavior he displayed at that time.  She states that the operation does not  use threating placement as a mean to get any child to comply.


summary: 748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous

raw_content: According to records, the current administrator at this operation is also an administrator at another operation.

Correction Narrative: Mr. Smith is no longer employed by this operation.


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

raw_content: A staff member made multiple comments to a resident that made the resident feel uncomfortable and unsafe with the staff member.

Correction Narrative: CORRECTION ACCEPTED PER PA SHELLIE ADETONA.  City of Hope Missions Inc has a grievance policy for each youth in our facility; that allows for any to file a grievance towards staff and/or peer. This is their right and opportunity to express any complaint or grievance to be answered without feeling punished or mistreated. This policy is gone over with all youth during their orientation to our program on the day of admission. If any grievance is submitted it will be reviewed by Administrator within a reasonable time frame. All youth are encouraged to submit when they feel as though their rights are being violated. If there is an emergency and a youth needs to report quickly; the Administrator is available to meet with the youth at that time. All staff have been trained on this policy and are expected to adhere to this policy. If there is a report that will need to be made into the hotline, that report will be made according to standard 748.303. I want it to be known that City of Hope did put parameters in place.


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

raw_content: Six drills were reviewed.  It was noted that one drill took 15 minutes to complete, one took 1:46 which is not clear if it was 1 minute and 46 sec or 1 hour and 46 minutes, one clearly states it took 1 hour and 30 minutes.   Another documented "less than 5 minutes" which does not meet the standard and one documents "NA" which also does not meet the standard.

Correction Narrative: Operation provided documentation that drills were complete and corrected documentation errors.


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

raw_content: One drill took  place 2/27/2020 and the next drill was completed 9/24/2020.   This was late.


summary: 748.303(e)(3)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness if an adult contracts a reportable communicable disease

raw_content: Two staff members texted positive for a communicable disease and CCR was not notified.

Correction Narrative:
Unfortunately, this incident was not reported timely but moving forward any serious
incidents will be reported within the appropriate time frame


summary: 748.1937(3) - Care for children and adults-adult resident may share bedroom with child if their age difference is less than two years.

raw_content:
Two residents were sharing a bedroom with there being more than 2 yrs. difference in age.   One resident was being discharged today so this was corrected at inspection.   Regarding 748.1937(2)  Care for children and adults-assessment/approval by PLSP for adult resident to share bedroom with child must be documented in child's record.  The operation also failed to produce documents regarding this standard but it's non compliance is being combined with this standard.

Correction needs to address how to maintain compliance going forward.


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

raw_content: A child in care was subjected to physical abuse by a operation staff member.


facility_name: Texas Tranquility Estates, Inc.

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: As of 2/25/26 the data that was due by 10/15/25 for restraints between July and September 2025 and the data that was due by 1/15/26 for restraints between October and December 2025 has not yet been reported to Licensing.

Correction Narrative: Operation has submitted EBI reports for July and September 2025 and October and December 2025.


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

raw_content: The position designated for a qualified full-time Care Administrator remains unfilled at this time.

Correction Narrative: Mrs. Egans: responded with New Administrator's information. Mrs. Celena Steward License # C03752 but shows expired. Mrs. Egans responded on 9/29/2025 with updated License #D13845 which shows a lapse, but letter attached shows license is valid through 6/12/2026.


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: During the monitoring team inspection, it was noted that the company vehicle did not have current registration nor was there a current inspection provided. February 2025.

Correction Narrative: Vehicle registration was updated. A picture was received with the updated information.


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

raw_content: During the team monitoring inspection 2 out of 4 employee files reviewed did not contain the pre-employment reference checks.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: One out three staff files was missing current annual trainings.

Correction Narrative: The operation replied: My file the executive director, Tina Egans, was pulled and I failed to complete trainings certificates for all the trainings that I conducted with my team, which could have been avoided.  Moving forward Executive Directors training certificates will also be completed and file appropriately.


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

raw_content: One out of three child files reviewed had documentation indicating only a three-day notice was provided regarding the child's service plan team meeting.

Correction Narrative:
The operation responded: .  To prevent this from happening in the future, I have implemented the following measures:
1.	Enhanced Scheduling Protocols: All treatment plan meetings will now be scheduled with a minimum of two weeks' notice, unless there are urgent circumstances requiring immediate action.
2.	Automated Reminders: I have set up automated calendar reminders to ensure timely notifications are sent out well in advance.
3.	Staff Training: The team has been briefed on the importance of adhering to notice requirements to avoid any disruption or inconvenience.
4.	Process Review: Regular audits of meeting scheduling practices will be conducted to ensure compliance with notice policies.
I am committed to maintaining clear communication and meeting all procedural expectations moving forward.


summary: 748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it

raw_content: Two out of three child files reviewed did not contain the PLSP's signature on the child's service plan.

Correction Narrative:
The operation responded: To prevent this issue from happening again I will do the following:
Review of Procedures: I have thoroughly reviewed the existing processes to identify any gaps that may have led to the omission.
Training and Awareness: All relevant team members have been briefed on the importance of reviewing and signing documents in a timely manner.
Implementation of Checks: I have introduced an additional review step before filing documents to ensure all required signatures are obtained and verified.
Digital Tools: I am considering adopting electronic signature systems to streamline and track document signing processes.
Moving forward, I am committed to maintaining diligent practices to ensure compliance and uphold the standards expected by DFPS.


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

raw_content: One out of two children's medication records reviewed contained two medication logs with inaccurate counts in comparison with the actual number of medication left.

Correction Narrative:
The operation responded: Medication log had one incorrect log due to staff not following trained procedures on medication dispensing.  Staff person was reprimanded and retrained one-on-one and Texas Tranquility Estates had a refresher training with all staff on medication policy & procedures.
TTE employees are taught the following administering medication:
	    How to properly identify and administer each resident's medication in relation to the current medication list.
	    How to properly record the time, amount of medication dispensed, the remaining amount of medication and their signature on the medication logs for each resident.
	   How to ensure that the residents are properly taking their medication by closely monitoring the resident when administering medication, having the resident cough once swallowing medication and completing a visual inspection of the resident's mouth to ensure the medication was taken.
	    Monitoring the residents for any adverse side effects after taken medication.
	    Where psychotropic and over-the-counter medication are properly stored and locked away in its designated area.
	    Never leaving residents left alone with any medication and having direct visual of the resident when medication is administered.
	    Having the resident to recite their medication to ensure they are fully aware of what medication they are taking.
	    To notify the administrator immediately for any medication errors and or concerns.


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

raw_content: At the time of the inspection, 2 out of 13 employees did not have a current background check upon employment reinstatement.

Correction Narrative: Operation submitted missing background check information. The following email was recieved: I have attached to this email the background check for Ms. Whitley as well as background check history list which shows that Ms. Jones's background check is pending at this time.


summary: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

raw_content: At the time of the monitoring inspection, proof of a current health inspection was not provided.

Correction Narrative: Proof of current health inspection was sent via email.


raw_content: During a review of the records I was unable to obtain a current health inspection. The last health inspection noted was for 2/10/2020.

Standard Number / Description: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

Correction Narrative: The operation provided documentation of the health inspection being done on 2/26/2022.


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

raw_content: During the walkthrough it was observed that the freezer temperature was at 3 degrees  Fahrenheit. This was corrected at inspection when a staff member changed the temperature to 0 degrees Fahrenheit.


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

raw_content: A backyard water feature that is not currently being used has standing water and other debris inside. This enables the buildup of rainwater potentially presenting a hazard to children in care.

Correction Narrative: An email was received showing where the water feature had been covered using heavy mesh  material as a safety precaution for children in care. Compliance has been met.


facility_name: Haven of Rest Care Home

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

raw_content: It was observed that the documented reasons for several medications prescribed to a youth in care on their medication administration logs did not match the reasons documented in the medication management records and the youths service plan that was provided.

Correction Narrative: Received a corrective action plan from the administrator stating the following: Effective immediately HORCH Management will ensure that all medical information will be accurately recorded to reflect the instructions of healthcare providers. These instructions will be clearly documented in medication logs, service plans and monthly reports. Staff administering medication will be advised of any changes are made to the administering of medication. All staff members will be instructed on DFPS Minimum Standards regarding maintaining accurate records in all documentation.


summary: 748.2261(a) - Operation employs professional who prescribes psychotropic meds-Professional evaluates & documents child's response to the medication quarterly

raw_content: The last medication management document provided was last completed in October of 2025. There was no updated information that indicated that Aripiprazole or Clondine was discontinued in December or any indication in the documentation that the youth was having any side effects to the medication in the discussions.

Correction Narrative:
Received a corrective action plan from the administrator stating the following: Haven of Rest Care Home will always obtain documentation from the prescribing healthcare professional, detailing the reasons for medication and the side effects of the medication.  This information will be discussed with both the youth and staff as well as the youths caseworker. Should the dosage of the medication change, or medication be discontinued, documentation will be obtained from the healthcare provider, and all parties will be advised in writing of all progress notes, monthly reports and the Service Plans for the youth will reflect this information.

The Minimum Standards cited has been reviewed with and explained to caregivers.


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

raw_content: A staff member did not follow the operations policies by falling asleep during work hours while supervising children.

Correction Narrative: Staff and children were interviewed regarding supervision.  The staff indicated that they had a training on ensuring there is no sleeping on shift and went over the operations policy.  The children confirmed and did not make any outcry.


summary: 748.1937(a)(4) - Adult in care may share room with child in care if child is 16 years old, age difference does not exceed 24 months; req. of 748.1931 and 1933 are met

raw_content: There was an 18 year old adult child in care sharing a room with a 10 year old and 11 year old.


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: A suicide screening was not completed at admission for a 12-year-old child.

Correction Narrative: An email was received from the Administrator on 04/05/25 stating that the Administrator and PSLP of Haven of Rest Care Home will review DFPS Minimum Standards related to suicide screenings as well as the Operational Policies of Haven of Rest Care Home.  The screening assessment will be added to the admission documents.  The screening will be a requirement for all admissions.  Additionally, caregivers will be educated on additional information related to suicide prevention. Copies of the new screening tool was received on 04/18/25 during a follow up inspection.


summary: 748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old.

raw_content: A child was discovered absent from the operation for more than 2 hours and was not reported within the required timeframe.

Correction Narrative: An email was received from the Administrator indicating that staff were retrained on the timeframe of reporting to Licensing and the police when a 612-year-old leave the premises unauthorized. The Administrator stated that they had a staff meeting on 04/14/25 & 04/16/25 to discuss the reporting process. They will also go over it again on their next staff meeting which is scheduled for 05/02/25 & 05/03/25.  He will send in the sign in sheet once completed. The sign in was received for the training.