summary: 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times

raw_content: The facility lacks required postings.

Deficiency Narrative: The facility lacks required postings.

Correction Narrative: Pictures of required posting have been reviewed an meet compliance


state: TX

facility_name: Prime Residential Care

summary: 748.111 - Child-care policy required

raw_content: The policies need to reflect detailed information on child care policies.

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

Category: Organization and Administration

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: facility submitted a child care policy which has been uploaded into sharePoint


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

raw_content: The policy lack plans to provide a backup care giver in case of an emergency.

Correction Narrative: Back-up designation was added to the Resident Policy on 8/6/21.


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

raw_content: The chairs on the back patio has crack in them and are not clean.

Category: Physical Site

Standard Risk Level: High

Corrected at Inspection: Yes


summary: 748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers

raw_content: The policy lacks detail on what the volunteers role at the facility will initial

Standard Risk Level: Medium Low

Correction Narrative: Explanation of volunteer role was expanded to include all duties of direct care staff.


facility_name: Sound Decisions LLC

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

raw_content: During the investigation; multiple employees  backgrounds were listed active who is no longer associated with your operation after 7 day of leaving.

Category: Individual Standards Evaluated


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

raw_content: All children in care stated that a staff member yells when the children are in trouble.

Standard Risk Level: Medium High

Correction Narrative: I, Brittany Gilcrest RCCR, contacted Dr. Lewis to reminder her of the comply by date of 11-9-2021. Dr. Lewis stated that she was not sure what response she wanted to give to the concern but will send it by the due date of 11-9-21. As of 11-10-2021 I have not received a response, as of now Sound Decision is not actively operating, there are no staff nor are there children placed in their care. With no active staff or children at the operation Sound Decision is currently able to follow to standard.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: It was determined that a staff member violated a condition of her background check.

Correction Narrative: I received the following follow up from Dr. Lewis on 7.22.2021 "This has already been corrected. Additional staff has been hired to ensure that Sound Decisions follows the conditions specified. In the future when we receive a background check that is provisional or with conditions, the CBU representative will be contacted to better understand those conditions to ensure they are adhered to."


summary: 748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: The downstairs kitchen did not have hot running water. There was no work order provided.

Correction Narrative: During a follow up inspection there is now hot water in the kitchens and bathrooms.


summary: 748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times

raw_content: Two of 4 bathrooms were not equipped with toilet paper and hand towels. This was corrected during inspection.


summary: 748.3441(n) - Food Preparation-Food must be protected from contamination

raw_content: Food was not in plastic(sugar and cereal). It was not covered or plastic bags. Boxes were not closed. This was corrected during the inspection.


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

raw_content: Two broken chairs were removed during the inspection.


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

raw_content: A caregiver has been working at the operation, having access to children in care, for two weeks without an initial background check.

Correction Narrative: I received an email from the operation 7.22.2021 stating "This has already been submitted yesterday and addressed. The background check is pending. The staff was removed from the schedule until background check was completed returned. The schedule and documentation was provided on 7/20/21."


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: It was concluded that a staff at the operation interfered with child in care from making a phone call to the Hotline.

Correction Narrative: The operation emailed stating "LCCA will ensure that all clients are allowed to use the phone to call the Hotline when needed. The staff have been retrained on Child Rights"


summary: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

raw_content: A serious incident report did not provided details that occurred including what led up to the altercation, police involvement and the child eloping from the operation.

Correction Narrative: LCCA will ensure that all staff completely documents serious incidents and will review the document before filing and sending it out. The staff have been retrained on Documenting and reporting. An upcoming training is scheduled September 1. 2021.


raw_content: Conditions on a background check for one staff member were not being followed as required.

Standard Number / Description: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

Correction Narrative: The operation is currently closed. There are no children in care.


raw_content: Operation allowed new staff member to work prior to receiving a notification from background check allowing the person to be at the operation.

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


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

raw_content: In reviewing children's records.  One child's medication log was found in another child's record.


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

raw_content: Personnel records are not maintained at the operation.  One staff member who was in charge of records carried them in a tote bag and would take the records out of the operation.


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

raw_content: One staff member administered medication to children at the operation.  The staff member did not have training to administer medication.


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

raw_content: A child in care did not receive prescribed medication for three days as a result of the operation misplacing the prescription.

Correction Narrative: An email was received from the operation stating "LCCA will ensure all medication is in the correct location. Medication is in the Pharmacy Closet and each locked drawer is labeled with the specifics of what is stored. During the weekly medication audits, medication location will be verified. Staff is required to initial in print after reading all medication notes. Any new prescriptions will be received and logged. Policy was updated." The operations medication training and medication policy was also provide.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: It was reported a staff member makes negative comments towards children.


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

raw_content: Food in the freezer was not kept in original packaging and stored in non-labeled bags.


summary: 748.341(a) - Operating policies retention requirements - Maintain copy at operation available for review upon request

raw_content: The operation failed to provide a copy of the child's preliminary service plan as requested.

Correction Narrative: An email was received from the operation stating "LCCA reviews all service plans and collaborates with the client case manager to ensure the inclusion of all required information as well as completion of all required signatures. In the event signatures are not received from service team members outside of the organization, documentation will be included to display attempts. Staff changes have been made to address this issue." The operations medication training and medication policy was also provide.


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

raw_content: In review of medication logs there were inconsistencies with the daily pill count documented.

Correction Narrative: An email was received from the operation  stating "LCCA will ensure all staff received adequate trying prior to the administration of any medication. Staff receives training through three sources including but not limited to (Bemaj Pharmacy, DFPS training, and SD Medication Training). When staff makes medication errors, retraining will be conducted followed by a posttest addressing the issue noted in the medication error. LCCA or nurse will complete a weekly medication audit as well as random medication audits to verify accuracy and efficiency. Policy was updated." The operations medication training and medication policy was also provide.


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

raw_content: Two children and two staff, including the Administrator expressed concern with unfair treatment.

Correction Narrative: The operation is currently not operating and does not have any children in care.


summary: 748.1117(1) - Documentation of searches-Document the date of the search in the child's record

raw_content: It was determined that there was a search conducted without any documentation.

Correction Narrative: LCCA will ensure that all staff complete search documentation as no later than 2 hours of the search. All search will be documented and placed in the clients file.


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

raw_content: It was determined that the medication log did not reflected the dosage based on the prescription.

Correction Narrative: LCCA will ensure that all medication records are filled out on the form. In the event needed, missing information will be requested, and a medication error form completed if needed.


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

raw_content: A child in care was unsupervised long enough to cut and dye her hair without staff being aware

Correction Narrative: The operation emailed stated "LCCA will ensure that all staff is monitoring clients closely and no more than 20 minutes will past without adequate supervision. Retraining was provided in this area."


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

raw_content: It was determined that documentation was not provided upon request.

Correction Narrative: The operation sent an email stating "LCCA will ensure that all records are available for review and reproduction. Staff changes have been made to help facilitate the goal. The operations have a new acting Client Case manager."


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

raw_content: During an unannounced inspection at the operation one staff was observed supervising ten children. There were no additional direct care staff present/on the premises at the time.


summary: 745.8417 - Licensing must have access to records

raw_content: During the inspection, no employee records were available for licensing to review .


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

raw_content: Three staff and two children confirm that two staff members that are employed with the operation and have had access to children in care prior to submitting or receiving results of an initial background check.


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

raw_content: Three of the four children stated that they are not allowed to use the bathroom that it in their bedroom unless the other bathrooms are full.  One of three staff stated that the children have to walk through the living room to use the hallway bathroom at night.

Standard Risk Level: Low


summary: 748.535(2)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operations LCCA failed to oversee   the staffing  to ensure supervision to meet the child's need.

Correction Narrative: The operation is no longer operating


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: The upstairs air condition was out of order for two days and one night where children bedroom were present. There was no alternative sleeping arrangement offered by the operation.

Correction Narrative: An email was received from the operation stating "LCCA will ensure that all repairs are made timely, and in the event sleeping arrangements are needed, LCCA will ensure the operation documents and  provides the needed accommodations." During my initial inspection I observed the home and equipment in clean and good condition.


summary: 748.3359(1) - Bedroom Space-Rooms commonly used for other purposes cannot be used as bedrooms

raw_content: A child in care was not provided a mattress for her bedroom in result the child slept in the common room.

Correction Narrative: The operation emailed "LCCA will ensure that all clients in care have a mattress, there are extra mattresses and mattress covers on site. Corrected the next morning." During my initial inspection I observed mattress for each bedroom and interviewed all children that stated that they all have a bedroom.


summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content: The child in care was not given a mattress based on the available mattress being soiled even with a mattress cover. Clean mattress were stored in a sperate garage.

Correction Narrative: The operation emailed that stated "LCCA will ensure that all clients in care have a mattress, there are extra mattresses and mattress covers on site." During my initial inspection I observed clean mattresses for each bedroom.


summary: 748.401 - Archived child record-kept safe from damage and available for Licensing review within 48 hours.

raw_content: The operation did not provide documentation in a timely manner, licensing had to repeatedly request therapy notes for a child in care.

Correction Narrative: The operation will ensure the documentation and files are onsite or correspondence that reflects attempt to acquire information.


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

raw_content: Fire exit doors were locked during inspection. Child had to ask to have door unlocked to go out the door.

Correction Narrative:
Compliance evaluated at inspection conducted 6/23/21. In compliance.

I received a Correction action plan from Dr. Lewis stating "On May 06, 2021, Dr. Lewis corrected the action prior to the conclusion of inspection. Staff was provided a verbal notification concerning doors being unlocked for safety reasons. On May 19, 2021, Dr. Lewis followed up with a written reminder regarding the exit doors being open for safe exit. Please see attached." During the physical walk through the doors were locked.


raw_content: Bathroom located upstairs was locked during inspection and 2 staff stated the children do not use this bathroom and they have to cross a public area to take a shower.

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


raw_content: During my inspection I when into living room to find 9 children and 1 staff. The staff stated that her partner left to take a child to a doctor appointment but will be right back. This left staff at a ratio of 1:9.

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


summary: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

raw_content: A child has been in care for over 90 days, there is no written waiver requested to Licensing.


raw_content: The operation failed to send documents in a timely manner even after multiple reminders.

Standard Number / Description: 745.8417 - Licensing must have access to records


summary: 748.363(9) - Personnel records-Include proof of request for background checks

raw_content: One of four staff files were missing the request for background check. Two of the four staff files were missing the job description. One of four staff files was missing a record of TB screening. Two of four staff files were missing the Affidavit for Applicants for Employment. One of four staff fiels was missing the operational policies signature. One of four staff fiels was missing the signed abuse/neglect statement. Four of four staff files were missing documentation of the person s performance with the operation.


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

raw_content: During the walk through there was a frozen carton of Silk being thawed in the kitchen sink. A picture was taken of the carton of Silk. Staff placed the Silk in the refrigerator during the inspection.


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 staff member was aware that the child in care had a heart condition. The child in care was placed at Sound Decision Llc, and the staff member failed to provided the required medication prescribed.

Correction Narrative: Staff members will continue to be adequately trained in this area. Currently, Sound Decisions has renamed the positions of Case manager and will utilize the checks and balance system to ensure that all clients' needs are meet.


summary: 748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health

raw_content: A staff member failed to complete required follow up for a child in care.


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

raw_content: 2 out of 4 children records have inaccurate dates on service plans.


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

Category: Safety and Emergency Practices

Deficiency Narrative: Fire exit doors were locked during inspection. Child had to ask to have door unlocked to go out the door.


summary: 748.1271(1) - Emergency Admission Documentation-Include brief description of circumstances necessitating emergency admission

raw_content:
4 out of 4 child's plan is missing specifications on how the child's supervision needs will be addressed, if there are issues or concerns that may escalate the child's behavior, a person is not designated for meeting the child's needs.

1 out of 4 child's file does not have a preliminary service plan and has been in care over 45 days.

Category: Admission, Service Planning, Discharge


Deficiency Narrative: Bathroom located upstairs was locked during inspection and 2 staff stated the children do not use this bathroom and they have to cross a public area to take a shower.


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

raw_content: 1 child in care over 45 days does not have an intital service plan completed.


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

raw_content: 3 out of 4 children's preliminary service plans are missing required signatures.


Standard Number / Description: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

Deficiency Narrative: A child has been in care for over 90 days, there is no written waiver requested to Licensing.


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

raw_content: During walk through there were 6 children downstairs in the common area without a staff member. They were unsuervised for approxiametly 7 minutes.


raw_content: The LCCA of the operation was not property supervising the case manger responsibility as well as all medical directives leaving the child's health at risk.

Standard Number / Description: 748.535(2)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children


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

raw_content: The child in care did not receive the required medical treatment needed.


raw_content: Due the lack of attention and failure to pass on details of the child's treatment as well as follow up with medical professionals. The child's diabetes was not controlled and the risk of future health issues due to the inability to control the diabetes was present.

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


facility_name: Horizon Project

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

raw_content:
During a review conducted on November 5, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, 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 again.

Further details of the administrators failure to ensure compliance include the following:
Your operation was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025.  The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan.

-       Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring.

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

Correction Narrative: An HM extension was approved effective 11/5/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 5/5/2026.


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: It was determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify.

Correction Narrative: Medication was reviewed for 3 youth and found to be compliant. The operation stated when administering medications staff will follow prescribing health-care professionals orders prescription by the start date of the medicine and the end date of the medicine which if it continues or discontinued or changes. Staff was retrained on how to administer medications on 4/12/25 and 4/14/25.


raw_content: Chicken was being thawed out in the sink.

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


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

raw_content: The injury of a child that required medical treatment was not reported to the child's case worker immediately.


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

raw_content: One of the childrens incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount.

Correction Narrative: Active child records once completed by staff will be check by manager and then compliance officer will check for current accuracy.


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

raw_content:
The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers.  The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression.
Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation.  Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents.

Correction Narrative: Service plan coordinator will document the service that the resident is required to have, and then it will be implemented and followed according to the service plan.


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

raw_content: It was observed that all beds did not have a required mattress covering or protector.

Correction Narrative: 03/05- The operation provided documentation showing the invoice for the purchase of new water-resistant beds.


raw_content: CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident.

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

Correction Narrative:
Children were interviewed regarding supervision and no concerns were found.

An email was received from the operation: Staff will make sure he gets enough sleep before his shift and move around more so he can provide the level of supervision necessary to ensure each child's safety and well-being, the shift supervisor will check on him to make sure he's providing the necessary supervision while on duty. Follow by inspection will be completed during the next HM inspection.


raw_content: A child was not administered medication as prescribed according to the instructions of the health-care preofessional's orders.

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

Correction Narrative: Operation provided me with copy of the medication training sign in sheet for 10-22 and 10-26 and photo was taken


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

raw_content: There is no indication on the medication error documentation as to when it was documented or anything regarding the healthcare physician being contacted.

Correction Narrative: Operation administrator told me that refresher training was completed for staff and provided me with copy of the medication training sign in sheet for 10-22 and 10-26 and photo was taken.


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

raw_content: During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken.

Category: Training and Professional Development


summary: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents

raw_content: 1 Bag of Krogger Pinto Beans was found to be open with beans inside in  the kitchen cabinet during the walkthrough of the Northeast Building.


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: During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed.

Correction Narrative: The operation sent its written correction via email. In its correction, the operation stated that the initial service plan will be sent out two weeks in advance, giving the parent(s) and the DFPS caseworker advance notice to attend the initial serve plan meeting.


raw_content: There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL.

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

Correction Narrative: The operation sent its correction via email. In its correction, it stated that When logging in an AWOL in the incident log staff will make sure the incident report is consistent with the log by documenting accurate and checking both incident report and log to make sure it's completed.


raw_content: During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24.

Standard Number / Description: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents


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

raw_content: One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children.


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: One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23.

Correction Narrative: This standard has been reviewed with the staff and the medication will be administered by the designated staff and doubled check by a manager/supervisor/shift leader that will initial the medical record for quality assurance to prevent this from happening in the future.


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

raw_content: During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection.


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: During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection.


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

raw_content: During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113

Correction Narrative: Written correction was sent by the operation. In its correction, the operation stated that The Serious Incident Reports involving unauthorize absences of children will be reported sooner than 6 hours. The reporter will report the unauthorize absences to statewide intake to ensure to meet the deadline. The administrator also informed me that he is going to have a conversation with staff regarding this issue.


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

raw_content: Child's service plan does not clearly document the child's supervision needs, but instead is generalized.

Correction Narrative: During the follow up inspection today, The Administrator told me that service plan coordinator will be specifying the supervision needs of each child individually in every youth service plan moving forward. The operation also sent this written correction via email


raw_content: It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage.

Standard Number / Description: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

Correction Narrative: Follow was completed on 8-1-23. During the follow up inspection, it was observed that the damaged tiles in children restroom (East Building) which resulted to citation during the last HM inspection has been repaired. Photos of the repaired work was taking upon approval.


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

raw_content: It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts.


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

raw_content: Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries.

Correction Narrative: 2 staff were interviewed, and they confirmed that meeting was held with management, and it was discussed that SAMA technique and prevention intervention will be used when necessary. Staff were also advised on her to effectively handle verbal altercation, so it does not escalate to physical. The operation also provided me with written correction.  The operation recently completed refresher training on supervision on 21st and 23rd October 2023


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

raw_content: 2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture.

Correction Narrative: 2 staff were interviewed, and they confirmed that they had meeting with management, and they were advised to ensure that they are staying very close to residents to enable them respond timely during any verbal altercation between residents. The operation also provided me with written correction. The operation recently completed refresher training on supervision on 21st and 23rd October 2023.


summary: 748.3231(b)(1) - Evacuation-Plan requires person in charge during emergency to designate an employee to call the fire dept in case of fire, explosion, toxic fumes

raw_content: The evacuation plan policy did not address who will be designating an employee during an emergency.


facility_name: Westlake House LLC

summary: 748.753(c)(3) - Pre-employment Screening- You must document your assessment of the applicant's suitability to work with or around children.

raw_content: There is no documentation showing that the applicants suitability was assessed.

Category: Personnel


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

raw_content: The operations recreational activities log does not include daily indoor and outdoor activity options.

Category: Recreation Activities

Correction Narrative: The operation has updated their recreational activities calendar to meet compliance with indoor and outdoor activities.


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

raw_content: Upon reviewing two of two children's records they are missing multiple required records.

Correction Narrative:
The Professional Level Service Provider and treatment director are responsible for completing these tasks and will ensure that all forms are completed within the appropriate time frame, printed, shared, signed, dated, and placed in the individual child's binder.
Westlake House LLC corrective action plan is to assign the Lead/Supervisor the task of auditing each individual child's binder weekly or until completion to ensure that all required documents are filed in the binder. The lead/supervisor will provide an audit sheet to the licensed administrator with the status of each child's binder.
In the event there are missing documents, the lead/supervisor will email the professional level service provider, administrator, and treatment director requesting documents to ensure missing documents are secured immediately.


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

raw_content: One of the two child files were missing the 72 hours plan.


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: Two of the Two children's records reviewed were missing admission's assessments.


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

raw_content: One out of the two children's records were missing an initial service plan.

Correction Narrative:
The operation emailed over a copy of the childs initial service plan.

The Professional Level Service Provider and treatment director are responsible for completing these tasks and will ensure that all forms are completed within the appropriate time frame, printed, shared, signed, dated, and placed in the individual child's binder.
Westlake House LLC corrective action plan is to assign the Lead/Supervisor the task of auditing each individual child's binder weekly or until completion to ensure that all required documents are filed in the binder. The lead/supervisor will provide an audit sheet to the licensed administrator with the status of each child's binder.
In the event there are missing documents, the lead/supervisor will email the professional level service provider, administrator, and treatment director requesting documents to ensure missing documents are secured immediately.


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

raw_content: While reviewing the children's medication records, it was found that the log shows 5 pills should be remaining in the pill pack, but 6 pills remain in the pill pack.

Category: Medication

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


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: Form is missing a place for how the operation will meet the needs. Also who will be responsible for meeting the needs of the child.

Correction Narrative: New form was provided with the corrections. Form is in SharePoint.


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

raw_content: The form is missing a place for the child or children's date of admission. Also a place for an update if it was an awol  and the child returned.

Category: Reports and Record Keeping


summary: 748.1205(a)(13) - Include any risk factors/warning signs and safety plan staff/caregivers will implement related to the risk factors and warning signs

raw_content: The form is missing a spot to indicate if a suicide risk screening is needed and any results of that screening.


summary: 748.1217(b)(16) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child.

raw_content: The form is missing a spot for the child's understanding. Also missing the operations determination of meeting hte needs.


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

raw_content: Form is missing place for persons allowed to leave the operation with and other medical consenters.


summary: 748.1219(4)(C) - Treatment Services Admission-Child's history/recent behavior indicates danger to self/others: Evaluate operation as appropriate to meet child's needs

raw_content: Form is missing a spot for if the child is a danger to others.


summary: 748.1219(1)(D) - Treatment Services Admission-ED or ASD: Admission assessment includes consideration of any history of inpatient or outpatient treatment

raw_content: The form is missing a place for inpatient/outpatient history.


facility_name: Harmony Family Services, Inc. Emergency Shelter

raw_content: In a review of the preliminary service plan, it was noted that the service plan was completed 5 days after the child's admission date.

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

Correction Narrative: RCCR inspector received follow up from administrator on 1/12/26. As of January 5th, all preliminary service plans have been completed within 72 hours of admission to the shelter. The administrator met with Program Director on January 5th to remind them of the 72-hour deadline for initial service plans. The operation has had three admissions since that date (on January 7), and all are in compliance. The administrator will continue to monitor all new intakes for compliance as well.


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

raw_content: During the inspection walk-through, the cabinet that the psychotropic medication (was not double locked), all other medications, knives, and multiple other objects was found defective as the handle was locked, but the kick plate was not holding the door shut. The handle itself was locked, but the door was able to be pulled open. The van keys were also stored in this closet, allowing access to the child, when they overheard the door was broken. Three staff were aware of the broken door prior to the incident.

Correction Narrative:
RCCR Inspector conducted an in person follow up at the operation on 11/12/25. There were no children present at the time of the inspection. Both the director and administrator were interviewed. The closet door leading to the medication is locked and cannot be pulled open. Inside is a locked box, holding all the medication. This box cannot be opened without a key. The house and van keys are kept in a separate locked cabinet where only staff have access. Staff were retrained in reporting policies when something at the operation is broken and needs repair.

RCCR inspector received follow up compliance from Administrator on 10/31/25. GRO director put a metal lock on the medication door on 9/15/25, to secure the medication closet and instructed the staff to keep the van and shelter keys in the locked staff cabinet in the utility room when not in use. A new medication door was installed with a new frame on 10/16/25, with the metal lock attached as well to use as a backup in case this problem occurred again. Also attached is a signed statement by the shelter staff acknowledging being retrained on the policy and procedure for reporting broken things in the shelter and where to store the van and shelter keys when not in use. Photographs of new door and sign in sheet can be found in the document library.


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

raw_content: Medication logs for four children did not document the reason the medication was prescribed.

Correction Narrative: Inspector received an email from the Administrator on 8/2/24. The program director retrained the staff on 7/24/24 regarding medication policy and documentation. This training was added to digital 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:
Five children reported a staff member ran a red light and had to slam on the breaks to not be hit by another vehicle, with children in the car. Three children reported they had been left in the car by the same staff.
A staff member made an inappropriate comment to a child in care about their beliefs.

Correction Narrative:
The inspector received the following email from the administrator on 8/16/23:
The employee in question was terminated from employment when the allegations arose. The operation's policy and GRO minimum standards about transporting children were reviewed with other staff by the administrator on 8/16/23. A sign in sheet is attached. This was added to digital storage.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: One child's medication log had 4 missed dosages that did not have medication errors completed.

Correction Narrative: The administrator emailed the Inspector medication errors for the 4 missed medication dosages. The staff involved were notified of the errors and all staff received re-trainings on administering medications and timely documentations of any medication errors during the weekly staff meeting on 10/5/22.


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

raw_content: Agency management staff failed to ensure that caregiver was following safety plan as caregiver was allowed to transport child and be within close proximity to the child. Caregiver did not follow the safety plan restricting direct contact with a child, who was displaying inappropriate relationship with the caregiver.  Caregiver was placed on disciplinary action prior to this incident where it was noted that any more incidents would result in immediate termination.  Although the caregiver violated the plan after the disciplinary action, caregiver was not terminated.

Correction Narrative: An email was provided by agency administrator stating administrative/management staff will continue to protect the health, safety and well-being of children in care by providing supervision and oversight of caregivers in the shelter and following any safety plans that are in place.


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

raw_content: It was found that an employee was terminated on 6/08/21 and shows as active as associated with the organization as of 6/23/21, 15 days after being terminated.


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: It was found that a child in care was given a dose of Vyvanse in the afternoon when they were supposed to receive a dose of Clonidine which caused an adverse side effect.

Correction Narrative: The operation sent a formal letter detailing their plans for correcting this deficiency and their plans for the future. They state that they staff member that made the medical error was terminated. They also state that they provided a refresher course in administering medications, steps to take in case a medication error occurs, and reviewed the licensing standards addressing the issues to all of their staff which was completed on June 23rd.


facility_name: Unique Teen

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: Police responded to the incident; however, licensing was not notified.

Correction Narrative: The administrator reported that once the Child has been called into Fort Bend Police and an officer is dispatched to the home to initiate the report, and an Incident number is provided, staff on shift will immediately report the Incident number to the administrator and the administrative team to ensure licensing is notified within the minimum requirement of 24 hours. This will be done via email to ensure the communication is reported in a timely manner.	Administrator/ Administrative Team. As well as CEO


raw_content: Operation staff left child at behavioral hospital without a bed available. Operation staff refused to sign for child at hospital once a bed became available stating they are not designated medical consenters. When operation was called to return for child they refused saying they had already submitted a 24-hour discharge for child and child was no longer their responsibility.

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:
Corrections submitted via email 5/26/25:
 Policies will be updated to read "Anytime a resident is taken to the hospital for any reason, the LCCA will make sure there is a staff member present with the resident until admission. In the event there is no bed available or there is a change to the admission plan, Unique Teen staff will remain with resident until they are either admitted or discharged back to Unique Teen or the residents caseworker and team."

LCCA and CEO will ensure staff completes intake process till child is admitted into hospital per operation Policy.

The CEO, LCCA and Treatment Director will work together to ensure that staff taking child to hospital will sign child in when bed is available and not leave hospital till child has been fully admitted. Staff will notify LCCA and CEO upon completion of child admitted.

Ms. Kimberly Bass is no longer employed at the operation reducing risk to children.


summary: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

raw_content: Child in care was not administered a suicide risk screening after initial screening.

Correction Narrative:
The operation provided the following compliance response on 12/03/2024:

Case Manager will complete assessment according to Unique Teen Policy.

The CEO, LCCA and Treatment Director will review the completed assessment to ensure completion and necessary protective measures are implemented.


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

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

Correction Narrative: Treatment director was determined to be qualified during third initial inspection based on the updated credentials for the treatment director, and it was verified that the operation is outsourcing services for the children in care.


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

raw_content: An employee application did not have the applicant's employment history.

Correction Narrative:
The operation provided the following compliance plan:
When screening a potential employee, the CEO or the Administrator will use the Texas Health and Human Services Pre-Employment Screening template and contact two references to verify if the potential applicant is suitable to work with and around children.  Method of contact and attempts to contact references will be documented in Pre-employment Screening Template.


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: An employee's file indicates that references were not contacted.

Correction Narrative:
The operation provided the following compliance plan:
When screening a potential employee, the CEO or the Administrator will use the Texas Health and Human Services Pre-Employment Screening template and contact each employer with the method of contact and the number of attempts for each employer listed.  The operation must contact each employee's three most recent employers if the applicant has had more than 3 employers in the past 5 years. Five-year employment history will also be added to the Unique Teen Employment application.


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

raw_content: Backseat passenger seatbelt cannot be fastened/secured.

Category: Transportation

Correction Narrative: Inspector received email with photograph of recipet from repair shop for seat belt repair dated for 3/7/2024 and picture of seat belt secured properly on this date. Inspector emailed LCCA to remind of compliance plan needed for submission.


facility_name: Adiee Girls Rosenberg, Inc

raw_content:
It was found that a staff member escorted residents from the operation to a discount department store, purchased phones for the youth, and offered children vapes.
It was also found that after allegations were made by the victims, the alleged perpetrator was informed of the allegations by another staff member. The alleged perpetrator then attempted to speak with the victims about the allegations.

Correction Narrative: The operation is no longer operating and no longer has children in care. Their license has been revoked at this time.


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

raw_content: Staff admitted to violating the operations policies when he transported children to a store, assisting the children in leaving the operation at an unauthorized time.


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

raw_content: A staff did not provide youth with a safe environment when he engaged in inappropriate sexual activity with children in their care. Staff confessed to law enforcement that he took the youth to Walmart, sexually abused them, and had naked photos of the girls on his phone.


facility_name: Devine Care Home RTC

raw_content: Staff failed to secure the cleaning product making them accessible to a child in care.

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

Correction Narrative: It was observed during the inspection that all cleaning supplies were properly stored and locked in a secure room. All cleaning supplies were checked to ensure they were properly stored and inaccessible to children in care. Staff were re-educated on the policy requiring all cleaning products and chemicals to be secured at all times when not in direct use.


raw_content: One resident was in the facility for 45 days and had not had a second suicide screening - required every 30 days.

Standard Number / Description: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

Correction Narrative: Emmanuel Ndukwe sent corrections for the suicide screening citation. Case manager and program director will ensure these screenings are done every 30 days to prevent suicidal ideation, and they also amended their admission assessment - which has been added to document library.


summary: 748.455(a)(3) - Unauthorized Absence - The debriefing should include the childs condition

raw_content: The unauthorized absence debriefing form did not have a section for the child's condition.

Correction Narrative: This information has been added to the debriefing form. See document library.


summary: 748.455(a)(4) - Unauthorized Absence - Debriefing includes where child went, who was w/ child, child activities & any other relevant info to their health & safety

raw_content: The debriefing form is missing a section for asking a child where he was, with whom, where they went, etc.

Correction Narrative: This information has been added to the debriefing form - see document library.


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

raw_content: One of the four employee files read had an incomplete pre-employment affidavit.

Correction Narrative: This deficiency has been corrected. Going forward the LCCA will ensure that all forms including the pre-employment applications are filled out completely and correctly.


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

raw_content: One staff member's file had no proof of high school diploma or GED.

Correction Narrative: The staff high school diploma was obtained as soon as possible and placed in her binder. Moving forward all direct care staff's high school diploma or GED will be in their respective binders upon hired. The LCCA and Program director will ensure that this is accomplished.


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

raw_content: Four of the four records contained CPI, TBRI, and CPR certificates with the operation's name misspelled.

Correction Narrative: The misspelled operation name has been corrected on all four of the CPI,TBRI AND CPR certificates. However, attached is the evidence to show that the correct operation's name was sent to the instructor. The LCCA and program director will ensure that true, accurate and complete records are maintained.


facility_name: SOLACE Residential Treatment Center LLC

summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: 2 of 3 files did not have admission assesmsments with all required information.


summary: 748.1205(a)(11) - Admission Doc-Includes treatment needs & any additional treatment services or programmatic services child is receiving

raw_content: 2 of 3 files were missing most of the requirements that are due at the time of admission.


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

raw_content: The operation did not  report the quartely emergency behavior report within the appropriate time frame.

Category: Emergency Behavior Intervention


summary: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: Three of the three staff records reviewed did not have 40 hours of experience documented. Operation had blank forms.

Correction Narrative: The staff was retrained by case manager. The staff will only be able to work with qualified staff during training time for observation.


summary: 748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level

raw_content: Two of the three children records reviewed did not have a child orientation. Operation could not provide orientation.

Correction Narrative: The staff created a new intake sheet to ensure all requirement documentations are present in the child's file. The staff will conduct monthly audits to ensure all children file have a required documentation and files are true and accurate.


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

raw_content: All staff records reviewed did not have a pre-employment screening assessment.

Correction Narrative: The staff will call and check all screening prior to staff being offered a position. All the staffs that were missing documentation were completed on 08/22/2025.


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

raw_content: One child in care was hospitalized, and no documentation was provided as to why child was not administered medication as prescribed by health-care provider.

Correction Narrative: Staff was prescribing proper prescriptions by a medical provider and started a new medication log. Staff discounted all unused and expired medications properly. Staff conducts daily audits to ensure all medication is properly administered.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: All children's records reviewed did not have a place to document child's religion and the child's religion was not documented.


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

raw_content: All staff records reviewed did not have the Pre-Employment Affidavit.


facility_name: Graceful Pathways LLC

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

raw_content: One staff file did not have any reference checks.

Correction Narrative: Graceful Pathways is no longer operating as of December 12, 2025. A compliance response was not provided by the operation.


raw_content: Two of two staff files did not have the required document.

Standard Number / Description: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.


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

raw_content: Staff allowed a child to walk out of the facility without staff supervision. Staff reported that they thought the child's service plan stated she could have 15 min alone time to deescalate however the service plan and deescalation techniques form do not reflect this.

Correction Narrative: The operation provided the following compliance response: Staff will have a constant audio and visual on residents at all times. Staff will continue to sit in the designated awake staff posts to make sure that they have a visual on residents at all times.  Administrative staff will review all service plans upon admission and inform staff. Staff will adhere to all recommendations lined out in the service plan.


raw_content: During the investigation, the operation provided an inaccurate documented account of a discussion had regarding shower time approval.

Correction Narrative: The owner of the operation submitted a corrective plan stating that the operation will complete the documentation within 24 hours and use timestamped entries to track it. Standardized templates will be used to ensure that staff follow the same documentation protocol and double-check entries for accuracy before submitting them. Two-person verification will be required for critical records, and documentation will include only facts written in objective language.


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

raw_content: Caregiver pushed a child in response to the child's behavior.

Correction Narrative: Licensing interviewed two children in care who both stated that staff are using corporal punishment techniques, nor have they witnessed staff using any corporal punishment techniques on their peers.  During the inspection, I observed staff's interactions with the children in care and the manner in which a child was redirected for their behaviors and no concerns were noted and threats were no made towards the children.  Licensing also interviewed two staff who reported to have completed training to ensure they are providing appropriate the appropriate care to the children.  The operation also provided the training rosters, PowerPoints, and policy discussed with the staff.  Staff reported to have weekly mandatory meetings and/or trainings to ensure compliance with the minimum standards.


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

raw_content: A caregiver was found to have damaged a child's property, which held sentimental value, as a form of punishment.

Correction Narrative: Licensing interviewed two children in care who both stated that staff do not damage their property, and they haven't witnessed staff damaging any of their peer's property. Staff reported that the operation conducts meetings and trainings in which they are taught what's considered appropriate punishment. Licensing interviewed the staff, and the reported disciplinary actions include incident reports and 15-minute cool downs followed by debriefing with the child.  Operation conducted a training with the staff to include trauma informed care.


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

raw_content: Child in care sustained a sprain to their neck and required medical attention, and this was not reported per minimum standards requirements.

Correction Narrative: Both children who were interviewed reported that they believe that the staff makes the necessary reports when needed.  They both reported that staff take good care of them. Licensing also interviewed two staff who reported to have completed training to ensure they are providing appropriate the appropriate care to the children.  The operation also provided the training rosters, PowerPoints, and policy discussed with the staff.  Staff reported to have weekly mandatory meetings and/or trainings to ensure compliance with the minimum standards.   Licensing reviewed the documents provided by the operation and mandated reported training was completed on September 17, 2025.


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

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

Correction Narrative: Licensing interviewed two children in care who expressed that their children's rights are not being violated at the operation.  Both also expressed that they feel safe at the operation and all of their needs are being met.  During the inspection, I observed staff's interactions with the children in care and the manner in which a child was redirected for their behaviors and no concerns were noted and threats were no made towards the children.  Licensing also interviewed two staff who reported to have completing training to ensure they are providing appropriate the appropriate care to the children.  The operation also provided the training rosters, PowerPoints, and policy discussed with the staff.  Staff reported to have weekly mandatory meetings and/or trainings to ensure compliance with the minimum standards.


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

raw_content: Two out of the two reviewed personnel records did not include the notarized Licensing Affidavit for Applicants for Employment.

Correction Narrative:
The operation provided the following compliance response: During my standard by standard, I was advised the affidavit that was currently being used was the form 2912 and no longer the affidavit that needed to be notarized. I did not request my staff moving forward to have it done. I have to date gotten all affidavits signed and notarized. I have attached the notarized affidavit for the (2) staff that were reviewed at the unannounced visit.  I have attached a copy of the two files that were reviewed.
Corrective action: Moving forward I will require that all new staff have the affidavit signed and notarized.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: A review of staff schedules and overnight logs reveals that background check conditions were not adhered to, as an employee was left alone with children in care.

Correction Narrative: During the interviews, three children in care and two staff members confirmed that they always have two staff members per shift to take care of the children. It was also confirmed that there is never one staff member alone taking care of children.


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

raw_content: Two records out of two personnel records reviewed contained incomplete reference checks as one record was not filled out completely and the second record did not have the second unrelated reference contacted successfully.

Correction Narrative:
The operation provided the following compliance response: Corrective Action: Administrative staff / case manager will ensure that all reference checks are completed as required prior to being hired. There is a Quality form that we use to make sure all documents are complete. Prior to being on the floor with kids, we will do a quality check and document. Personnel files will continue to be checked regularly for follow -up and compliance.
Attached the updated reference check.


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

raw_content: Review of two children's record found that the EBI policy explanation is not included in the orientation.

Correction Narrative: On 05/22/25, the operation provided documentation of the operation checklist noting that EBI is included as part of the orientation checklist.


facility_name: TRELS Home For Children

raw_content: There was contradicting information documented in the childs admission assessment reviewed.

Correction Narrative:
12/15/2025- compliance response received:
It was noted during the Heighten Monitoring inspection that there was information in the admission assessment that was contradictory. The admission assessment for the child was reviewed and corrected to ensure all information is accurate, consistent, and supported by documentation. The Case Manager will submit all completed admission assessments for supervisory review to ensure accuracy, clarity, and internal consistency prior to requesting signatures. The Case Manager will participate in a brief refresher training covering. The importance of maintaining true, current, accurate, and complete records per 748.151(3).


summary: 748.1009(2) - Child/caregiver ratio-Must employ adequate number of caregivers to meet their responsibilities regarding supervision of children in 748.685

raw_content: The operation did not provide 1:1 supervision according to the specific child contract for two of the nine children in care.


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 does not have a Treatment Director who is a full-time employee of the operation.


facility_name: Serenity Hope Home LLC

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

raw_content: During the inspection, it was observed that the tags on the fire extinguishers were expired.

Correction Narrative: Email a photo of the currently inspected fire extinguisher.


summary: 745.903(2) - Controlling Person - Submit Controlling Person Form to Licensing within two days after a person becomes a controlling person. See TAC 745.901

raw_content: Staff member was not added to the controlling persons after official hire date.


facility_name: Renew Group LLC

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

raw_content: During the investigation, it was discerned a child was not supervised within the 1:1 ratio prescribed in his Service Plan.

Correction Narrative: On 12/29/25, the operation submitted a written correction plan stating the service plan had been updated to depict the specific time frames during which 1:1 supervision as required by the SSCC plan.  The plan also states the LCCA will be responsible for ensuring service plans accurately reflect services put in place in accordance with SSCC plans.  The LCCA is also identified as being responsible for ensuring proper staffing during the 1:1 supervision hours to meet supervision needs.  On 12/30/25, the operation provided the updated service plan for Hayze, the updated Exceptional Care Request denoting his hours of 1:1 supervision, and a sign in staffing plan indicating the individuals assigned to provide Hayze's prescribed 1:1 supervision.  These documents have been uploaded to Document Library. This brings this standard into compliance.


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

raw_content: During the investigation, it was discerned staff was locked out of the house for several minutes and could not enter the building to intervene with threats made by an irate child.

Correction Narrative: On 12/29/25, the operation submitted a written correction plan stating the operation will complete a training on 12/30/25 addressing practical application of strategies to improve situational awareness which would prevent recurrence of the incident leading to the citation.  The LCCA is set to lead the training, and this training has been added to the annual training requirement for staff.  On 12/30/25, the operation conducted an in-person training regarding situational awareness and supervision expectations and provided a copy of the sign in sheet.  The operation also presented a copy of the updated service plan for Hayze, A copy of the Exceptional Care Request denoting the time frames of his 1:1 supervision expectations, and a staff schedule illustrating which staff would be supervising him during those timeframes.  Following the service plan expectations for all children in the group appropriately would have avoided the circumstances of this incident, wherein one staff was locked outside during the altercation, and these efforts will increase staff support in the house, reducing the chance of recurrence.  These documents have been uploaded to Document Library.  This brings this standard into compliance.


summary: 748.863(a)(5) - Pre-Service Training- Caregivers who administer medication must have psych medication training before administering psych meds.

raw_content: Employee administers psychotropic medication and has completed the DFPS online training but hasn't completed the instructor led training.

Correction Narrative: All staff completed training with Pharmacist technician 05/30/2025. After completion certificates will be placed in employee files and verified by staff. Moving forward training will be completed during pre-service training and documented on the pre-service training log and certificates placed in employee files. To be verified by staff after on-boarding and training complete prior to being scheduled for shifts.


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: Operation admitted to using a pill organizer for medication administration and prepared the medication a week in advance by removing from package and moving to pill organizer.

Correction Narrative:
As of 05/23/25 all medications have been returned to the original prescription bottles. Medications will only be pulled during medication time only. All medication is now being replaced with blister packs, so they are administered at the specific time.
Staff will be responsible for signing into the medication binder at the start of their shift and pulling and signing the medication log as medication is passed at the designated medication times.
Training will be completed with each staff to ensure comfort with medication on 05/30/25.


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

raw_content: All medication records were evaluated, and none were observed to reflect the reasons that the children were prescribed the medications.

Correction Narrative:
On May 27, 2025, the operation provided the compliance plan: Current MAR sheets were edited 05/27/2025 by LCCA to include the reasonings for prescribed medication for each youth, for each medication.

Moving forward when MAR forms are completed monthly, the reasoning for each will be indicated for each child, for each medication.  To be completed monthly or as new medication is added by LCCA or designee.


facility_name: Horizon Heights Children's Home LLC

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

raw_content: Caregivers failed to ensure that a child was given medication as prescribed.

Correction Narrative: Follow-up by inspection.


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

raw_content: One medication was administered twice but not documented on the medcation log.


raw_content: Child and personnel records did not containt documents for review readily available.


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

raw_content: The operation did not have a current unauthorized absence log available for review.


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

raw_content: Two child records reviewed did not contain initial service plans.


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

raw_content: Two medications did not have an accurate medication count.


summary: 748.1217(b)(6) - Admission Assessment-At admission, must include current medical & dental status, including available results of medical/dental exams

raw_content: One child's admission assessment did not include information related dental examinations.

Correction Narrative: Per email from CEO, the admission assessments were updated in all child records to include dental status and exam results. The Administrator will receive refresher training in completing admission assessments, with emphasis on documenting both medical and dental history. The Admission Coordinator will use a checklist at intake to verify that all sections, including dental, are completed before the file is finalized. The Program Director or designee will review all new admission assessments within 48 hours of intake to ensure compliance.


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

raw_content: Two out of two child records did not have information related to medication side effects listed.

Correction Narrative: Per email from CEO, the preliminary service plans were updated in all child records to include all education, medical and dental needs along with medication listed with side effects. The Program Director or designee will conduct a weekly file review to ensure all required documentation, including medication side effects, is present and up to date. A Quality Assurance checklist will be implemented to verify that all Preliminary Service Plans are complete before final approval.


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

raw_content: Two personnel records reviewed did not contain a document indicating the operational policies were reviewed by the employee.

Correction Narrative: Per email from CEO, the Personnel Policy Acknowledgement Form was modified and reviewed for compliance. The modified form will be signed by all staff. The operation will conduct policy reviewed every January and policy review meets with re-signatures as when policies are updated. Administration/HR will conduct quarterly personnel file audit. The modified form will be added to the onboarding packet checklist.


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: Two staff records reviewed did not contain reference checks documented in the employee file.

Correction Narrative: Per email from CEO, the pre-employment screening template form will be used to document verified reference checks for all employees. This form will be stored electronically and in personnel files. The operation will ensure reference checks will be completed prior to hire approval. The Administrator will conduct monthly audits of new fire files.


state: AZ

facility_name: PILLAR WELLNESS SOLUTIONS VIII, LLC

summary: Compliance (Annual) - 11/13/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on November 13, 2025.

inspection_type: Compliance (Annual)


summary: Modification - 4/30/2025

raw_content: No deficiencies were found during the onsite modification inspection conducted on April 30, 2025.

inspection_type: Modification


summary: Initial Monitoring - 4/30/2025

inspection_type: Initial Monitoring


summary: Compliance (Initial) - 11/4/2024 - 11/14/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 4, 2024 and the off-site documentation review completed on November 14, 2024.

inspection_type: Compliance (Initial)


facility_name: PILLAR WELLNESS SOLUTIONS

summary: Compliance (Annual) - 11/13/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on November 13, 2025:

rule: R9-10-720.C.3. Emergency and Safety Standards C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on documentation review and interview, the administrator failed to ensure a current fire inspection report was maintained. The deficient practice posed a potential risk to the health and safety of a resident in the event of a fire if hazards had not been identified and corrected, and standards expected of the facility were not followed.

findings: 1. A review of facility documentation revealed a "Fire Department Operating Permit" which stated, "Expires: 05/31/2025." No documentation of a current fire inspection report was received during the on-site inspection. 2. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Modification - 4/28/2025

raw_content: No deficiencies were found during the on-site inspection to modify the population from children to adults conducted on April 28, 2025.


summary: Initial Monitoring - 4/28/2025

raw_content: No deficiencies were found during the on-site abbreviated follow-up inspection conducted on April 28, 2025.


summary: Compliance (Initial) - 10/21/2024 - 11/8/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on October 21, 2024 and the off-site documentation review completed on October 29, 2024 and November 8, 2024.


facility_name: HORIZON RECOVERY

summary: Complaint;Compliance (Annual) - 3/17/2026

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaints 00158571 and 00162059 conducted on March 17, 2026.

inspection_type: Complaint;Compliance (Annual)


summary: Complaint - 1/14/2026

raw_content: The following deficiency was found found during the on-site  investigation of complaint 00155142 conducted on January 14, 2026:

inspection_type: Complaint

rule: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on record review, documentation review and interview, the administrator failed to ensure a resident did not have access to any materials that may present a threat to the resident's health or safety. The deficient practice posed a risk as R1 gained access to a medication R1 was not prescribed and required immediate intervention by an emergency medical services provider.

findings: 1. A review of R1's medical record revealed R1 was not prescribed Benadryl. 2. A review of facility documentation revealed a document titled "Incident Report" dated in January 2026 and documented by E6. The document stated "Description of incident: Client came to the office wanting a tylenol for a headache. I was working on counting stock medication so the bin of stock meds was out of the closet sitting on the desk next to me. [E4] was on [E4's] computer. I was on my laptop trying to confirm that [R1's] parents gave consent for the tylenol. [R1] then asked permission to go into the lost and found bin which is right behind me. [E4] gave permission for [R1] to do so and while doing so, [R1] then quickly swiped a bottle of benedryl from the desk next to me and went out the side door and took unknown amount of pills." The document continued to state "Action taken: Immediately called 911. [E4] followed [R1] out the door and stayed with [R1] until first responders showed up. All necessary staff was contacted." 3. A review of facility documentation revealed a document titled "Incident Report" dated in January 2026 and documented by E7. The document stated "Description of incident: On the above date and time, the client [R1] reported a headache and requested PRN medication. Staff initiated the standard medication administration process, including review of the client's medical record to verify PRN eligibility per approved orders. During this process, the client requested access to the lost and found area. While staff were engaged in the medication review, the client unexpectedly obtained a non-prescription medication and exited the residence. The amount obtained was unknown. Staff immediately initiated the organization's elopement and medical safety protocols, including continuous visual monitoring from a safe distance and prompt notification of emergency medical services. Emergency medical services arrived on scene, assumed care, and transported the client to [a hospital] for medical evaluation. The event was managed in accordance with Horizon Recovery policies and procedures, appropriate notifications were completed and the incident was documented per regulatory and accreditation requirements." 4. In an exit interview, E1 and E2 acknowledged R1 had access to materials (an unprescribed medication) that endangered R1. E2 reported R1 was hospitalized and discharged from the facility to a higher level of care.