summary: 748.453(a)(3) - Unauthorized Absence  Annual summary log must include how long the child was gone or if the child did not return

raw_content: The facility does not have an annual summary log for a child who has an unauthorized absence

Correction Narrative: An Unauthorized Absence Annual summary log was developed and implemented for a child who has an unauthorized absence Attachment F).


state: TX

facility_name: Dream Residential Treatment Center, Inc.

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

raw_content: In review of 4 staff files,  I was found that three of the four staff members lacks the proper amount of EBI training hours before being counted into ratio.

Category: Training and Professional Development

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: Staff received EBI training on 4/20/2021 and certificates placed in their personnel files (attachment A)


summary: 748.863(a)(2) - Pre-Service Training-Administrative & professional staff must have 2 hrs normalcy training before designated or within 90 days of beginning duties

raw_content: Administrator is missing Normalcy training

Standard Risk Level: Medium

Correction Narrative: Darrell Spates LCCA completed 2 hours Normalcy training and certificate placed in staff's personnel file attachment D).


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

raw_content: Each child file reviewed is missing the child allergy information on the front of the file.

Category: Reports and Record Keeping

Correction Narrative: Allergy labels indicating known or no known allergies placed in the front of each child's record and clearly visible.


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: In review of two staff files, there is no documentation that verifies education requirements.

Category: Personnel

Correction Narrative: Robert Wilson and Rodrick Perkins documentation of their education requirements were placed in their personnel file (attachment C)


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

raw_content: In review of Drug test, it is found that staff is only being tested for Marijuana and nothing else.

Category: Individual Standards Evaluated

Standard Risk Level: High

Correction Narrative: 6 staff members tested with the appropriate drug testing method for Marijuana, Cocaine, Opiates, Phencyclidine (PCP) and Methamphetamine on 4/26/2021 (see attachment B) and results placed in their personnel file.  The remaining staff notified they are required to be retested by 4/28/2021.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: In review of restraint reports, there are no mention of what method of EBI was administered.

Category: Emergency Behavior Intervention

Correction Narrative: Incident Report was revised to indicate the method of emergency behavior intervention administered (attachment G).


facility_name: New Beginnings

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

raw_content: The fire drill log did not include length of time for the evacuation or relocation to take place.

Standard Risk Level: Medium Low

Corrected at Inspection: Yes


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 couch and recliner in the game room was observed with visible shredding and exposed cushioning.

Correction Narrative: During an inspection conducted related to an investigation on 09/24/2025, I observed the couch was removed from the game room and was confirmed to no longer be in the facility. The room was locked and marked as "closed for renovation."


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

raw_content: Bleach cleaner and rust remover were observed to be stored unlocked in the cabinet in the child's bathroom. Cans of paint were observed in the game room accessible to children.

Correction Narrative: During an inspection related to an investigation conducted on 09/24/2025, the child's bathroom was inspected and confirmed to have no hazardous or poisonous substances present.


summary: 748.3119(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect fire sprinkler system annually & conduct any required service or testing

raw_content: The fire sprinkler system next to the stove needs to be evaluated.

Correction Narrative: During this inspection related to an investigation on 09/24/2025, I observed a maintenance person evaluating and servicing the fire sprinkler system next to the stove.


summary: 748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations

raw_content: Employee files were observed to be unlocked and stored in the game room that children have access to.

Correction Narrative:
The following corrections were sent by the operation on 09/24/2025:

Children's files were moved and are now kept inside the administrative office locked in a file cabinet, effective immediately 09/17/2025.


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

raw_content: Two of two children's child rights forms were observed to have the incorrect date. In addition, the unauthorized absence log did not meet the required information documented.

Correction Narrative:
The following corrections were sent by the operation on 09/24/2025:

All items will be clearly checked for accuracy, effective 09/17/2025. Going forward, dates will be reviewed with the outside caseworker to ensure all dates are accurate.
Wel will conduct a brief training session with staff to emphasize the importance of accurate record-keeping and the need to verify documentation received from external agencies.


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

raw_content: Two children that eloped were not debriefed once they returned or within the allotted timeframe.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that debriefing about any unauthorized absence will be infused with staffing & Administration duties to ensure timely reporting. They will continue AWOL reporting checklist. Conduct daily review and monthly QA audits of incident logs. Provide refresher training on AWOL definitions and documentation. (Class or self-pace training)

The Facility Administration will ensure completion and proper documentation of this.


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: The operation did not report to licensing when two children ran away.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that staff reinformed of the robust protocol for reporting a serious incident report. Include best practices for implementation by retraining the staff, reinforcing crisis protocol, and include specifics.

The Facility Administration will ensure completion and proper documentation of this.


summary: 748.685(c)(4) - Caregiver responsibility - positively reinforce children's efforts and accomplishments

raw_content: A caregiver was encouraging children in care that they could leave the facility and run away.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning Staff members will undergo further training on how to focus on positive engagement and learning key communication strategies.

The Facility Administration will ensure completion and proper documentation of this.


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 recreation calendar did not list daily indoors and outdoors activities for each day.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that they will provide a balanced daily schedule combining indoor/outdoor activities daily.

The Facility Administration will ensure completion and proper documentation of this.


summary: 748.1303(4) - Education-Provide quiet, well-lighted space for the child to study and allow regular times for homework and study

raw_content: The operation would not allow the children access to their school computer to complete homework. The children were taken to school late numerous times.  The operation did not purchase the school supplies that the children in care needed.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that the daily schedule will have a spot allotted for homework and assignment completion. School supplies will be provided within twenty-four hours upon final registration into school. Staff members will sign a log deflecting the time of departure and return for the kids attending school.

The Facility Administration will ensure completion and proper documentation of this.


summary: 748.1501(a)(4) - Dental care-Children in care must receive dental care as needed for ongoing maintenance of dental health

raw_content: A child in care was not scheduled follow up appointments for their on-going dental treatments.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that after all appointments documentation will be audited, and a tracking system for follow-up
appointments will be made to ensure that all appointments will be made in a timely manner.

The Facility Administration will ensure completion and proper documentation of this.


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: The operation would not allow the children to make private phone calls to the Ombudsman or to their caseworker.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that they provide designated quiet space.

The Facility Administration will ensure completion and proper documentation of this.


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: The children were made to stay in their rooms for a long period of time. In addition, a staff person had called a child names regarding their weight and used "slang" comments regarding their sexual orientation.

Correction Narrative:
Provided by Email from Administrator on 04/02/2026: Effective immediately, New Beginning will ensure that Staff will focus on dignity and safety. Focus on positive affirmation. Emphasize Agency and voice. Emphasize privacy and autonomy.

The Facility Administration will ensure completion and proper documentation of this.


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

raw_content: Several individuals interviewed reported seeing cockroaches at the operation.

Correction Narrative:
Title of the person responsible- Supervisor and Facility Manager.
Action Plan- Pest control company has been ascertained to treat the facility as needed.


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 was given the incorrect medications for several days and documentation does not reflect that the correct prescribed dosage was being administered.

Correction Narrative: The medication logs for multiple children at the operation. The medication logs were properly filled out, and no child missed any medications. Medication dosages were accurate as well. The medication log of the child whose medication error triggered the deficiency was reviewed. The child's medication log and dosages were accurate as well. Multiple children placed in the home stated during interviews that they are getting all their medications at the right dosages, and their medications are counted and logged in the computer each day. Staff present during inspection stated no child is missing medications.  The operation's case manager stated the person responsible for the cited med error was terminated. The case manager stated she checks the medication logs daily to make sure the children get all their medications as prescribed by their respective doctors.


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

raw_content: It was reported that a child left the facility, obtained marijuana, and returned to the facility without staff knowing. There is no serious incident that documents the absence.

Correction Narrative:
Corrective Action
 Administrator
Update policy to require serious incident documentation for all AWOLs.
Continue AWOL reporting checklist.
Conduct daily review and monthly QA audits of incident logs.
Provide refresher training on AWOL definitions and documentation. (Class or self-pace training)
 Treatment Consultant/Therapist
Conduct risk and treatment review for involved youth.
Provide psychoeducation on substance use risks and facility rules.
Support staff with trauma-informed supervision strategies.
Develop monthly reviewed safety and accountability plan with the youth.
 Direct Care Staff
Maintain active supervision and engage residents during transitions.
Conduct re-entry searches and debrief with youth.
Attend quarterly AWOL prevention/documentation training.
Completion Date: Within 30 days of CAP approval. Monitoring/Responsible Party: Administrator will monitor incident reports daily and conduct monthly QA audits.
Facility Response Staff were engaged with the resident throughout the incident. A staff member was talking to the youth during the AWOL attempt, actively trying to de-escalate and convince him not to leave. The staff located the resident and returned him to placement.
 Administrator
Review 1:1 supervision log monthly for compliance.
Provide ongoing training on service plan implementation and documentation.
Conduct spot checks to ensure staff adherence.
 Treatment Consultant/Therapist
Review youth's service plan and AWOL risk factors.
Staff training on trauma-informed AWOL interventions.
Update and review safety plan as needed
 Direct Care Staff
Document interventions and supervision with specificity.
Attend quarterly training on 1:1 supervision and AWOL protocols.
Completion Date: Within 30 days of CAP approval. Monitoring/Responsible Party: Administrator will monitor service plan logs monthly and review quarterly with DFPS.
Revise policy on contraband response in bathrooms.
Provide mandatory staff training on balancing privacy with prudent judgment.
Ensure suspected drug use is documented with immediate actions taken.
Conduct random supervisory checks for compliance.
 Treatment Consultant/Therapist
Provide psychoeducation on risks and consequences of substance use.
Staff on therapeutic responses during suspected contraband use.
Refer the youth for immediate drug screening to confirm suspected use and guide treatment planning.
 Direct Care Staff
Maintain active supervision in restricted areas.
Notify Administrator immediately if drug use is suspected.
Attend quarterly training on DFPS standards, supervision, and contraband management.
Completion Date: Within 30 days of CAP approval. Monitoring/Responsible Party: Administrator will review all suspected contraband reports monthly and provide quarterly DFPS updates.
Overall Monitoring & Compliance The Administrator will:
 Continue to review logs of all incidents, AWOL reports, and supervision notes.
 Conduct monthly quality assurance audits.
 Review CAP implementation quarterly with DFPS. All corrective actions will be completed within 30 days of CAP approval and sustained through ongoing training and monitoring.


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

raw_content: A child in care requires intense level of care and 1:1 supervision according to his service plan but he eloped from the facility and returned without staff being unaware.


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

raw_content: It was reported that a staff member waited patiently at the bathroom door while a child in care smoked marijuana.


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

raw_content: Multiple staff files reviewed have no record of annual training. The operation reports they were unaware staff was required to complete an annual suicide prevention training.

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


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

raw_content: No record of documented fire and severe weather drills was available during 6/23/2025 monitoring inspection.

Category: Safety and Emergency Practices


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

raw_content: Files reviewed show an active employee that transports youth has a driver's license that expired 8/3/2023.

Category: Transportation

Correction Narrative: The operation has now come into compliance.


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: A child in care is being administered non prescription medication and there is no medication record for given medication,

Correction Narrative: This standard was evaluated and found to be in compliance.


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

raw_content: The medication log advises that a child was given medication on at 7:40pm on 5/12/25, however that time have not come. The medication log also advises that the remaining pill count is 25 as on 5/12/25, however there are only 24 pills in the pill pack.


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 currently does not have a full-time Treatment Director.


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

raw_content: One child record reviewed found medication count does not match with medication documentation.

Category: Medication


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

raw_content: Background checks for an employee who was hired on 10/04/24 was not active at the time of inspection. His background checks were inactive as of 06/03/24.


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

raw_content: One staff record reviewed was missing proof of education required for the position.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: Psychotropic medications were not locked during the visit.


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

raw_content: One staff record reviewed was missing the TB screening result.

Correction Narrative: This standard was reviewed and found to be in compliance.


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

raw_content: Two staff record viewed did not include documentation of verifying the applicant's employment history.


raw_content: During interviews with operation staff, residents and school personnel, it was determined the residents are not being dropped off at the school, but instead are being dropped off at the McDonalds located next to the school.

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:
On 1.16.25, an in person follow up was conducted at the operation. Interviews with staff and residents confirmed that staff is now dropping the residents off at the designated drop off spot at the school.

On 1.14.25, the department received the operations written compliance plan via email. It stated that the operation will remind and refresh staff on the importance of dropping and picking up residents at the appropriate assigned school location. Going forward, all New Beginnings staff members will ensure residents are dropped off and picked up at the designated site of the school building.


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

raw_content: There are planks of wood in the backyard with multiple nails sticking out of them.

Correction Narrative: The backyard is clean with no hazards or planks of wood with nails.


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: Fire Extinguisher inspection expired March 2023.

Correction Narrative: Fire Extinguishers are up to date and in good condition.


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

raw_content: The serious incident report did not contain the date of admission for the child or the names of the staff members involved in the incident.

Correction Narrative:
New Beginnings has conducted additional Serious
Incident Training for staff members on how to properly
fill out the serious incident form.
Staff has been reminded and refreshed on what is
appropriate and suitable when completing a Serious.
Incident report.


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

raw_content: Multiple food items were observed not properly stored.


summary: 748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces

raw_content: Bleach and other cleaning supplies were observed in an unlocked pantry in the kitchen that also stores food.


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

raw_content: Staff member was preoccupied while caring for children.

Correction Narrative: This standard was evaluated and found to be in compliance. Since the citation, the staff has been refreshed on the technology policy regarding personal calls and the use of laptops.


summary: 748.507(3) - Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties

raw_content: Staff member did not follow operation's policy.


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

raw_content: During the course of the investigation it was determined that a caregiver was using profane language towards the children.


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 couch in the living room where children in care congregate and watch television is broken and poses a safety concern for children in care.


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

raw_content: A mattress that a child in care is sleeping on does not have a mattress cover. This was observed on the bottom bunk in bedroom number three.


raw_content: Staff were not aware that the children were engaging in inappropriate behaviors.

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


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

raw_content: While a safety plan was in place, stating that a staff member would not perform any restraints on any children, the named staff member did perform a restraint on a child.


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

raw_content: During an altercation between a staff member and a child in care, the staff member responded to the child posturing up to them by pushing them away from them.

Correction Narrative: This standard was evaluated and found to be in compliance. The staff has been updated on the policy regarding appropriate discipline. They also took additional training to correct the issue.


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

raw_content: During an altercation between a staff member and a child in care, the staff member reacted to the child's behavior by verbally threatening harm to the child.

Correction Narrative: This standard was evaluated and found to be in compliance. The staff was retrained on discipline and refreshed on the operation's policy.


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

raw_content: During the inspection, I observed that the operation lacks the required No Trespassing signs posted.

Category: Physical Site

Correction Narrative: Provider sent picture of posted "No Trespassing Sign." Picture can be found in Share Point.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: During the inspection, I observed that two of the three child records reviewed lacked immunization records obtained prior to non-emergency admission.

Category: Admission, Service Planning, Discharge

Correction Narrative: The operation provided documentation of the children's shot records via email and integrated them into the record.  The administrator verbalized understanding that these records must be secured prior to admission and indicated that he was considering creating a letter to send to workers upon acceptance clarifying required documentation for admission.  This brings this standard into compliance.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: During the inspection, I observed that 2 of the three records reviewed did not include documentation of the administered suicide screening in the child's record at the time of non-emergency admission.

Standard Risk Level: Low


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

raw_content: During the inspection, I observed that the posted evacuation diagrams do not include a designated meeting place outside the building in case of emergency egress.

Correction Narrative: The operation provided an updated copy of the evacuation diagram that includes a designated meeting spot by the mailbox in front of the building.  This document can be found in the Submitted Corrections folder for this inspection in RCCR Digital Storage.  This brings this standard into compliance.


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

raw_content: One staff members stated residents are restrained with arms behind the back. Another staff member stated for restraints, they put their hands on the kids and puts the kids on the floor; they stated restraints are not black and white, and there is no standard method of restraint. EBI trainer stated staff are not taught to control the child by any means necessary, nor do they teach any restraints against the wall or on the floor.

Correction Narrative: Standard was evaluated and found to be in compliance. The owner was present and stated that there are no children in care.  A walkthrough was conducted and it was confirmed that there are no children in care.  There is no risk to children and this standard was found to be in compliance.


summary: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child

raw_content: Staff member stated during interview they did push victim prior to restraint and did not accept the apology victim offered them. Two children confirmed staff member pushed victim to the floor.


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

raw_content: Two children confirmed victim was restrained on the floor.  Staff member confirmed victim was restrained on the floor and stated for restraints, they put their hands on the kids and puts the kids on the floor. Staff member also stated victim was on their back during this time. EBI trainer stated staff are not taught to control the child by any means necessary, nor do they teach any restraints against the wall or on the floor.


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

raw_content: Staff member stated during LE interview they held their weight down on victim until victim calmed down. This is documented in the offense report.


summary: 748.113(9)(A) - A person for filing a complaint, presenting grievance, or providing information relating to the misuse of EBI at the operation

raw_content: Two children in care were notified of discharge due to implementation of safety plan prohibiting the use of restraints on the residents during investigation.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: 3 of the 3 staff records reviewed did not include instructor led training for administration of psychotropic medication.

Correction Narrative: The operation provided updated training records.


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

raw_content: 2 of the 3 children medication records reviewed had incorrect medication counts. The medication counts did not match the medication documentation.

Correction Narrative: The operation sent an email of the medication records. The operation also provided a corrective action plan stating, "	To ensure that this discrepancy does not occurs again, all the staff have been retrained on the administration of psychotropic medication, accountability and reconciliation processes. Medication reconciliation will be conducted daily during every shift for the next 30 days to ensure accuracy."


summary: 748.3701(e)(2)(B) - Recreation responsibility-Child receiving treatment services-Ensure that children receiving treatment services has individualized recreation plan

raw_content: 2 of the 2 children records reviewed did not include individualized recreation plans for either child.

Category: Recreation Activities

Correction Narrative: The operation provided individualized recreation plans for the 2 children in care.


summary: 748.119(5) - Volunteer policy - Address volunteer contact with children in care

raw_content: The volunteer policy does not specify the volunteers contact with the children.

Category: Organization and Administration

Correction Narrative: The operation provided an updated volunteer policy.


summary: 748.531(a)(2) - Child-care administrator-Licensed according to HRC Chapter 43 and Subchapter N of Chapter 745

raw_content: The operation currently does not have a licensed child care administrator.

Correction Narrative: The operation emailed me advising me that Mr. Kayode Omotayo passed his LCCA test and will be the operations administrator.


summary: 748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child

raw_content: The operations discipline policy fails to integrate trauma informed care information.

Correction Narrative: The operation provided an updated policy.


summary: 748.3065(a) - Gas Inspection-Gas inspection report must show operation's gas system is free of leaks, must include inspection date & inspector name, phone number

raw_content: The operation has not had a Gas Inspection conducted.

Correction Narrative: The operation provided an email with their gas inspection attached.


facility_name: Seton Home

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

raw_content: Form 2912 was not found in the reviewed personnel files.

Correction Narrative: Email received from operation on 10/30/2025. Form 2912 has been added to the onboarding packet for all applicants and will be distributed to all staff who began employment since September 2023 for completion (not requiring notarization) and those forms will be entered into the employee records. Administrator will ensure all newly released standards regarding personnel files and applicants will be shared with Human Resources to ensure compliance. Staff responsible include Human Resources Generalist and the Vice President of Programs (Administrator).


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

raw_content: A staff member playfully hit a child on their arm. This staff member also used profane language in the presence of children.

Correction Narrative:
In person Follow-Up at operation completed on 10/21/2025. Interviewed staff members and verified operation reviews and emphasizes the importance of professional boundaries. In addition, each employee was able to provide acceptable and appropriate discipline measures.Two staff members were interviewed to verify their understanding of personal boundaries and appropriate disciplines. Both staff members stated they are aware of maintaining professional boundaries with the children in care and "playfully hitting" a child in care is unacceptable behavior.
10/3/25-Email with Compliance Plan attached received. Administrative staff stated they are working to ensure each staff member completes their review of professional boundaries training.
Corrective Actions to be taken: Seton Home residential staff members will be expected to re-take professional boundaries training within 90 days of this action plan. Effective 10/01/2025, it is expected that this training be re-taken every 6 months.
Responsible persons:
All Staff

Shelter Supervisors
Residential Services Program Director

Corrective Action Plan Acknowledgement
The Corrective Action Plan will be in place effective immediately. Any changes made must be reviewed with the Vice President of Programs and the Executive Director.  Corrective Action Plan will be reviewed by Seton Home in 30 days. Failure to comply with the Corrective Action Plan and/or deficiency being issued for any of the above standards within the review period will result in disciplinary action to include termination.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: Psychotropic medications were not under double lock.


summary: 748.1269(a) - Emergency Admission-Complete all requirements for an admission assessment within 40 days of admission

raw_content: Admission Assessment for one child was not completed within 40 days of emergency admission.

Correction Narrative: Email received from operation on 5/2/2024 with Compliance Plan attached. The program director will provide an intake/admission requirements checklist to the case managers to utilize when processing a new intake. The primary case manager assigned to the child will complete the required tasks before their deadlines in accordance with Minimum Standards and contractual requirements. The Program Director and/or second case manager will audit the new intake's file to verify the required documents are completed prior to their due dates and communicate any findings, concerns or reminders via email to the assigned case manager, as needed.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: Operation staff verbally admitted a child in care's positive test result for COVID was not reported within 24 hours. The operation documentation indicated the test result was 10-06-2023 and the report was 10-11-2023.

Correction Narrative: Administrator provided plan that requires staff assigned to youth to report communicable disease(s) immediately upon receiving a positive test result. All staff was given a refresher training for what is reportable and how to document. Supervisor will verify reports are made.


summary: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules

raw_content: Provided Policies and Procedures did not comply with Standards found in Subsection C.

Correction Narrative:
RCCR Inspector received extension request from Administrator to ensure operation comes into compliance. One month extension has been granted on 10/9/2023.

RCCR Inspector received policies and procedures via email from Administrator Kari Stewart.

RCCR Inspector received text/email from program director asking for an extension, one month extension was granted.


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

raw_content: Operation did not have verification severe weather drills were being completed every 6 months.

Correction Narrative: Operation's Administrator provided compliance/corrective action plan with severe weather drills to be conducted in February and August. Scheduled drill dates will only be known by Shelter Supervisor, Vice President of Programs and the Program Director.


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

raw_content: During the walk through it was observed that paint cans were stored in bottom cabinets underneath the sink in the kitchen.

Correction Narrative: All cabinets clear of hazardous materials. Cleaners and other hazardous materials locked in storage room.


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

raw_content: During the walk through it was observed that multiple beds did not have either mattress covers or protective covers on the resident's beds.

Correction Narrative: All beds have mattress covers


summary: 748.1531(b)(2) - Medical Care-Written record of each medical examination must include the follow-up treatment recommended and any appointments scheduled

raw_content: While reviewing the medical documentation for the child's medical exam, it was advised that the child follow up with her PCP within 3 days.  Staff was unable to take child to follow up with her PCP within that time frame.

Correction Narrative: Operation created and implemented a checklist when handling medical documents to be completed by the Medical Coordinator or Program Assistant to ensure all medical advice is followed through in a timely manner and in accordance with treatment recommendations. Additionally, the Program Director and Program Assistant will conduct bi-weekly evaluations of medical files to verify appointments and follow ups are being completed. In cases of resident refusal to attend appointments and incident report will be created and placed in the resident's file.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: The operation documentation provided revealed no evidence that the operation reported a child in care's positive COVID 19 test results to the DFPS hotline within 24 hours.

Correction Narrative: On 02/22/22 RCCR Inspector Annie Bagnato received an email with a corrective action plan from Kari Stewart VP of Programs. The assigned case manager for the child in care will make a hotline report within 24 hrs. of awareness that a child has contracted a reportable communicable disease. Residential service program director will service as a backup reporter if the case manager is out of the office or otherwise unavailable.


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

raw_content: Staff member's file had Affidavit for Applicants for Employment  but it was not signed.

Correction Narrative: Seton Home's Human Resources Generalist will verify completion of the notarized Licensing Affidavit for Applicants for Employment form prior to the employees start date.


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

raw_content: Through interviews and review of medication logs, it was found that medication was not administered as prescribed due to child in care not receiving prescribed medication.

Correction Narrative: Documentation provided by the operation indicates that they will have all employees who administer medications will receive updated training on the administration of medication, documentation of the administration of medication, and medication error reporting.


facility_name: South Texas Adolescent Rehabilitation & Education - STARE

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

raw_content: A bedroom window was observed to have the plexiglass kicked out, granting access to the outside backyard.


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

raw_content: Operation's last sanitation inspection was 12/5/2024. The next inspection is not scheduled until 12/26-12/27 per Administrator.

Correction Narrative: A copy of the updated health inspection was provided via email from the provider.


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

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

Correction Narrative: Operation has reported the count of EBI for this quarter and will report every quarter to remain in compliance of standards.


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 four child medication records, there were discrepancies found in the pill count vs. the medication log.

Correction Narrative: All medication will be reviewed to ensure tablet counts are accurate and align with the documentation in the medication logs.


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

raw_content: Two serious incident reports lacked sufficient detail and time frame of when the incident occurred.

Correction Narrative: All serious incident reports will be thoroughly filled out with details and time of occurrence.


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: Child received an injury to the face after an inappropriate restraint.

Correction Narrative: This standard has been reviewed and found to be compliant.


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

raw_content: Staff was upset and did not control his physical response to a child in care.


summary: 748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed

raw_content: Staff did not use any method of de-escalation prior to using an inappropriate restraint that caused an injury to a child.


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: The allegations are related to a DFPS abuse/neglect investigation.

Correction Narrative: .This standard has been reviewed and found to be compliant.


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

raw_content: During files being reviewed during inspection, a staff member file did not have a tuberculosis screening showing the employee is free of contagious TB.

Correction Narrative: Employee has submitted a copy of TB screening showing that employee is free of TB. The agency requests a TB screening after the prospective employee's background check is approved.


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

raw_content: It was found during the inspection that a job description was not included in staffs' file.

Correction Narrative: All staff concerned have signed personnel record and same placed in their files. The case manager will ensure a job description is included in all files. The files will be reviewed monthly by the administrator to ensure compliance.


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

raw_content: During inspection a staff member was observed to have no documentation or verification of education from a high school, college, or equivalency.

Correction Narrative: Staff concerned have submitted a High School Diploma. The agency requires new employees to submit this document prior to having access to children. The administrator checks the file for the documents prior to orientation.


summary: 745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access

raw_content: During inspection staff members files were reviewed and there was no current drug test prior to date of hire and re-hire.

Correction Narrative: All employees concerned have submitted a negative drug screening. A drug test is requested by the agency prior to a new employee having access to children and randomly. The administrator checks the file for the results prior to the new employee being allowed to begin orientation.


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

raw_content: During inspection staff members files observed did not have verified employment history and/or references.

Correction Narrative: Staff concerned employment history has been verified; and references checked. The agency requests a TB screening after the prospective employee's background check is approved.


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

raw_content: During the inspection a staff member file was observed to have no current record of TB screening conducted prior to re-hire.

Correction Narrative: Staff concerned has submitted a clear TB test indicating staff remains free of TB. The HR person is responsible for filing the document and the administrator or designee checks the file to ensure that all required documents are present prior to person starting their job.


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

raw_content: During inspection staff files were observed to be missing current and updated files, documents, and mandatory paperwork needed prior to hire and re-hire.

Correction Narrative: Operation has initiated a file for all records as needed. The case manager is responsible for creating and maintaining all files. The files are reviewed monthly by the administrator to ensure compliance.


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: During inspection staff files observed did not have signed affidavits prior to hire and re-hire.

Correction Narrative: Employee concerned has submitted a signed pre-employment affidavit..  The HR person is responsible for filing the document and the administrator or designee checks the file to ensure that all required documents are present prior to person starting their job.


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

raw_content: It was found during the inspection that the annual fire drill was not completed per the log that was reviewed.

Correction Narrative: Operation has conducted the fire drill and evacuation drill. The operations QA person is responsible for requesting fire and evacuation drills at the required timeframes. The house manager conducts the fire drills and documents the drills as required by minimum standards.


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: Multiple mattresses on the top bunks were observed to have the bottoms ripped out of them.

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


summary: 745.621(a)(3) - AP Initial background checks submitted - At the time you contract with someone who requires a background check

raw_content: An contract worker does not have an active background check.

Correction Narrative: South Texas Adolescent Rehabilitation and Education RTC (STAREIHOUSE) will maintain and monitor compliance by conducting periodic background checks and eligibility records by the Administrator.


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

raw_content: One of the 16 seats in the van the children are transported in has a seat belt that does not buckle.

Correction Narrative:
The seat belt has been ordered for replacement and will arrive within 4-7 business days.

An in person inspection was conducted at the operation where the seat belt was observed to working correctly.


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

raw_content: Two showers at the operation had mildrew built up around the showers corners.


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

raw_content: Staff is using profane language towards children and around children.

Correction Narrative: Compliance response received on 2/9/23: All the staff at STAREI HOUSE has been instructed to refrain from using language that may be considered profane while present in the home


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

raw_content: In review of seven child medication records, there were four discrepancies found in the pill count vs. the medication log.


summary: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

raw_content: Three of three children files reviewed did not consist of an updated service plan.

Correction Narrative: Received an email confirmation from the operation stating all updated service plans has been placed in their respective file binders.


raw_content: The logs to document the nightly checks that were required for the safety plan were pre-filled.  One staff admitted that logs were regularly pre-filled.

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

Correction Narrative: This standard has been reviewed and is now in compliance.


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

raw_content: A safety plan requiring two staff members be present at night was not followed when   there was only one staff member inside the operation for a period of time on .


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

raw_content: Both staff were interviewed multiple times and continued to be inconsistent with their stories about the whereabouts of one of the staff.


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

raw_content: First aid/ CPR certification expired 6/1/22.

Correction Narrative: The operations was able to provide me with an updates copy of the staff members CPR/ First Aid card.


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

raw_content: The operation has not had a sanitation/Health inspection completed.

Correction Narrative: The operation has submitted a copy of the last health inspection that they have had completed and meets compliances.


summary: 748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.

raw_content: The operation has not developed an unauthorized absence log.

Correction Narrative: The operation was able to send me the Unauthorized absence form that they will be using for their log.


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: Operation did not report the Serious incident timely to the hotline timely. The child sustained injury on March 7th and was taken to the doctor on March 8th. The doctor refereed the child for an Xray of his hand on March 11th and the Xray was completed on March 14th and the result indicated the child sustained fracture to his finger and was referred to orthopedic for a higher level of care. The operation did not report the incident to the hotline until March 21st which is 14 days after the incident.

Correction Narrative:
Follow up by phone call was conducted on 3/28/22 with the operation Administrator.

Written corrections were submitted by the agency on 4/1/22. The agency stated that it will report any incident to the state hotline on a timely manner according to the minimum standard.


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

raw_content: The shower in one of the bathrooms has mold and the sink in that same bathroom is not draining properly.

Correction Narrative: The operations emailed over photos that the mold in bathroom has been cleaned away. Photos have been uploaded to into sharepoint


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

raw_content: The backyard of the operation has two broken wooden planks on the fence


raw_content: The last row in the 12 passenger van had one seat belt that would not pull out and one of the seats buckle is broken

Standard Number / Description: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

Correction Narrative: The operation has emailed photos of the seat buckles in the 12 passenger van that has been fixed. Photos have been uploaded into SharePoint.


facility_name: Sanctuary of Hope

summary: 748.1101(b)(3)(L) - Children's rights-Based on child's age/maturity seek employment, keep own money/bank acct, paid for work done at op except for chores as discipline

raw_content: Teenager in care is not allowed to seek employment until after graduating high school.

Correction Narrative: An email was sent on 2/4/25 stating a new policy had been implemented. Residents of the Sanctuary of Hope can seek part-time employment under the following guidelines: Residents may work either at the Sanctuary of Hope or with a pre-approved employer. Residents may work up to 12 hours per week, depending on their schedule. Residents must open a checking and savings account with assistance from a parent or legal guardian. Residents are prohibited from opening a credit card account Residents must deposit 70% of their wages into a savings account and cannot withdraw funds without approval from their parent/legal guardian and the Sanctuary of Hope. This policy is in place to encourage financial responsibility. SANCTUARY OF HOPE PERMISSION FORM was sent an email.


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

raw_content: When reviewing the activities calendar for September, October, and November, it was observed that mutliple days did not have planned recreational activities.

Correction Narrative: An email was sent 11/14 24 with the updated recreational calendar. The operation current Recreational Calendar and Daily Activity Schedule were combined as suggested to show the scheduled Daily Recreational Time. Residents are encouraged to share ideas for recreational time based on individual ability and interest during community meetings. The attached Daily Activity Schedule is available to every resident and posted to the common area bulletin board. The Recreational Calendar will be updated and posted to the common area bulletin board monthly.


raw_content: Staff should not try to deter a child in care from seeking medical care.

Correction Narrative: An email was sent to the inspector on 12/18/24 stating that the operation created a training and shared it with staff through emails and followed up with in-person discussions or phone calls to the staff that work overnight or weekends. The inspector interviewed three children in care, and none had had concerns with staff. All children in care stated that the staff is respectful and that their needs are being met. Two staff members were interviewed and stated that training for medical needs and children's rights had been completed.


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

raw_content: Medication records did not include the daily count for medications administered to the children in care. Operation does not operate as a cottage model as staff confirmed only a volunteer resides on-site and not a house parent or daily staff therefore, this is required to be documented.


summary: 748.511 - An employee, contract service provider, or volunteer may not be in possession of a handgun while at your operation or while caring for children.

raw_content: Contract security was present on-site inside the operation with a handgun attached to their body and in the presence of children.

Correction Narrative:
3/11/24, in person follow-up inspection was completed at the operation. The operation was able to provide the inspector with the security officer's Basic Security Officer Training Course Level Three certificate of completion to carry a firearm. The operation has placed the variance and the certificate in the office where security is stationed. The operation confirmed that only security officers with a Basic Security Officer Training Course Level Three certificate of completion can carry a firearm.

An email was sent on 2/26/24 stating, that firearms safety trained contract service providers/security officers will not carry weapons on Sanctuary of Hope property. The operation has submitted a variance requesting the firearm safety-trained contract service providers/security officers be permitted to carry weapons while on duty at Sanctuary of Hope. The operation stated that based on the decision of Childcare Regulation, Sanctuary of Hope reserves the right to request an administrative review, if necessary.
The operation was able to provide the inspector with the security officer's Basic Security Officer Training Course Level Three certificate of completion to carry a firearm. The operation has placed the variance and the certificate in the office where security is stationed. The operation confirmed that only security officers with a Basic Security Officer Training Course Level Three certificate of completion can carry a firearm.


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

raw_content: Licensing observed and photographed an outlet cover exposed in bedroom three.


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

raw_content: While reviewing employee files out of four files one did not contain a job description.

Correction Narrative: Email was received from administrator with attachment showing job description completed and added for employee file and plan utilize checklist of employee documents in all files.


summary: 748.1933(b) - Care for young adults-may admit young adult to program, other than transitional living, only if certain conditions are met

raw_content: Operation admits young adults who were not admitted through transitional living program as the program for transitional living is not currently operating.

Correction Narrative: An email was received on this date from case manager supervisor outlining the parameters of the transitional living program.


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

raw_content: While reviewing operation policies it was noted that there was not an annual summary log for unauthorized abscences.  When requested, operation administrator reported they did not have a log.

Correction Narrative: Email received from administrator including annual summary log for unauthorized absences. Administrator reported she will check logs monthly and has set monthly reminder on Outlook Calendar.


summary: 748.124(a) - You must adopt the model suicide policy in 748.125 of this division or another policy that is approved by the Executive Commissioner or designee.

raw_content: The operation failed to complete and submit a suicide policy for approval  by the required time frame of March 18, 2023. The operation was notified via email of the due date and responded prior to.

Correction Narrative: Suicide policy received on this date and approved on 5/4/2023


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

raw_content: While reviewing the serious incident report form it was noted that the form did not include the name of the operation, address, or phone number.

Correction Narrative: Email received from administrator including updated serious incident report template to include physical address, name of operation, and phone number. Administrator advised document will be saved and located where staff can easily access it.


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 out of three child records reviewed did not have a signed orientation within the 7 days.

Correction Narrative: Sanctuary of Hope has modified the document to reflect the addition of all orientation topics listed.  The operation will ensure they have been discussed with the resident for awareness and understanding within 7 days of date of admission'.  This form will be present in all new intake resident binders.


facility_name: My Friend's House

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

raw_content: Operation did not submit EBI information for quarter 3.

Correction Narrative: The operation submitted EBI data for the third quarter. The operation set automatic calendar reminders to go off before the due dates to ensure the data is submitted timely. The operation added more staff to the calendar reminders as an extra layer to ensure compliance.


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

raw_content: Two child files did not contain documentation that the children's parents were notified of the initial service plan timely.

Correction Narrative: Agency Director contacted RCCR Inspector to discuss follow-up. Training was conducted with the Case Managers regarding service plan meetings.


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

raw_content: Operation could not provide document of a serious incident report during inspection.

Correction Narrative: Operation provided documented SIR for this incident as well as plan moving forward to ensure that all SIR are documented correctly. Documentation located on SHAREDRIVE


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

raw_content: Supervision protocol was not followed as a child was left at the operation alone.

Correction Narrative: Operation submitted a plan to address ongoing for the operation that states, during the Supervision and Special Actions section of each child's Initial Service Plan, their case manager will adjust their supervision protocol based off their age and level of development. This will allow the operation to ensure adequate care and supervision of children. The initial service plan will also include unsupervised activities a child may participate in such as going to the movies, going on a jog, going to work, etc.


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

raw_content: Operation did not report second incident of children being left alone at movie theatre.

Correction Narrative:
RCCR received the following response in regard to the deficiency cited:
In response to the above investigation the following processes have been reviewed and amended. Creation of Serious Incident Report Excel Spreadsheet now includes additional verbiage found on the spreadsheet in red font to include when children are left without supervision at the shelter or on an agency outing.
The excel spreadsheet is used to assist in complying with minimum standard guidelines which include types of serious incidents, if a report needs to be completed for licensing and when, if parents/guardians need to be notified and when, if law enforcement needs to be notified and when, and if documentation needs to be written.
The excel spreadsheet is very specific and easy for all to follow. It is shown on the spreadsheet that anytime a serious incident occurs, a report to licensing needs to be completed. The report number will need to be gathered to put in the Serious Incident Report as well.
The excel spreadsheet is accessible to all staff and can be found in the staff office.

An excel spreadsheet was also submitted detailing what situations are deemed reportable to CCR. Documents will be uploaded to the Shared Drive.


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: Two fire extinguishers located in the kitchen and teen hall were expired.

Correction Narrative: On 06/13/22, an inspection was completed at the operation by RCCR Inspector, J. Walder. Fire extinguisher was in compliance.


summary: 748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value

raw_content: The food menu for children in care did not document any food substitutions on the menu.

Correction Narrative: An email was received with a document with the updated menu including the meal substitutions added.


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

raw_content: One out of four children files did not have the  child signature for their inital service plan.

Correction Narrative: This deficiency was discussed with the operation at the time of inspection. The child's file reviewed who did not have the signature for their  initial service plan had been  discharged from the operation.


summary: 745.621(b)(1)(B) - AP Renewal background checks submitted -No later than 2 yrs from date you last submitted subjects initial or renewal name-based TX criminal hist check

raw_content: Two staff that are current employees did not have background checks updated.

Correction Narrative: Background checks letters with approved eligibility for the two staff from the CBCU , from operation via email.  This information was also verified in the CLASS system. The two background check letters can be found in the operations file in digital storage share point.


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: A picnic table that had nails protruding wood was accessible to children in care.

Correction Narrative: On 05/29/20201 the operation sent a picture to Licensing of the area where the furniture was previously placed. It confirmed that the item was removed. The picnic table was large and could not be completely removed at inspection.


facility_name: Creighton Oaks Residential Treatment Center

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

raw_content: The CLASS system shows the most recent fire inspection was 04-09-2024. The operation had records of requests to have the inspection completed by 04-09-2025. The FIre marshall inspected the operation on 04-16-2025 and the operation didn't pass. The operation had a change in management and got a passing inspection on 10-06-2025.


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

raw_content: The operation had no documentation of any emergency drills in over six months.

Correction Narrative: An email was received on 10/21/2025 stating, the Administrator will ensure that all required severe weather drills are completed with current staff.  Moving forward, evacuation and emergency procedures will be emphasized as a critical component of new employee orientation and ongoing staff training to reinforce preparedness and compliance.  The Administrator will also ensure that documentation of all completed drills is properly maintained and submitted with the Plan of Action to verify compliance with this requirement.


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

raw_content: While reviewing files it was found that multiple items were missing.

Correction Narrative: An email was received from the Administrator stating, there will be a staff assigned to audit files for compliance weekly and ensure documentation is filed weekly. This staff will document requests for missing items and documentation. The administrator or designee or other management will receive weekly reports on auditing to ensure compliance.


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: 2 of 3 employee files did not have documented reference checks.


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

raw_content: A child in care obtained bullets from the operations van.

Correction Narrative: Each youth will be provided with the appropriate level of supervision necessary for their safety and well-being. This includes searches before entering the facility, searches when returning to the facility, searching backpacks and other possessions that youth leave the facility with. These possessions will be searched upon returning to the facility. Backpacks along with other necessary items will be left in the office or other designated area. Search forms will be completed and a log of searches will be obtained. If any contraband is found, it will be staffed with our team and the hotline will be called when necessary. The necessary parties will also be notified. Random searches will occur and logged. Staff will be trained on supervision defining within hearing and seeing distance that includes refreshers as needed.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: While reviewing video of the incident a child was inappropriately restrained.

Correction Narrative: 2/25/2025 information from the operation was received that stated Each staff will be provided with the facility's approved EBI training. Staff will not be allowed to restrain youth until they have completed EBI training and are certified. Staff will receive training during orientation. They will receive annual EBI training and refreshers. Refresher for EBI may occur as necessary. EBI training will occur to ensure youth the right to be free from abuse and neglect. Each staff will be trained on child rights and abuse and neglect during orientation. There will be refreshers on these trainings as necessary. Staff will be trained on how to identify and report abuse and neglect. Orientation will occur with each youth during initial placement explaining and reading their child rights. This includes instructions on how to report abuse, neglect, and exploitation.


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 caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.

Correction Narrative: On 2/25/2025 information was received from the operation that stated Each youth will be provided with the right to be free from abuse, neglect, and exploitation. Each staff will be trained on child rights and abuse/neglect during orientation. There will be refreshers on these trainings as necessary. Staff will be trained on the definitions and how to identify abuse, neglect, and exploitation. Instructions will be provided how to report abuse and neglect. This includes identifying it among co-workers and youth placed at the facility. Instructions and training will also be provided on how to report abuse and neglect. Orientation will occur with each youth during initial placement explaining and reading their child rights. This includes instructions on how to report abuse, neglect, and exploitation.


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 two doses of their morning medication.

Correction Narrative: Medication logs were reviewed and in compliance.  Staff supevisor will help be auditing night medicaiton logs to ensure they are correct.  The Administeator is also auditing  the medication logs.


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

raw_content: The operation did not report a child in care unauthorized absence to Licensing or their parent within the allotted timeframe per minimum standards.

Correction Narrative: An email was received on 11/14/2024 from the Administrator.  Staff were re-trained on Unauthorized Absences. New forms were created that they were trained on also. Staff involved was told they should not have delegated it to someone else and this is not acceptable.  The next 48 hours were spent coaching, guiding, and training the employee one-on-one. A training was provided for staff .


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

raw_content: There were several food items observed to be expired and without expiration dates in the library refrigerator/freezer.

Correction Narrative: The pantry and refridgerators were inspectioned, no expired foods were observed.  A system was put in place to complete a walk-through of the homes with a checklist to look for any physical site issues/expired foods at the start of each shift, twice a day.


raw_content: During the course of the investigation, it was revealed that multiple children in care stole equipment with the intent to sell, indicating insufficient supervision and increased risk to their safety.

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

Correction Narrative: The facility has a new administrator that has provided line of sight supervision training using demonstration and scenarios where staff must be interactive and respond how to supervise youth. Staff are given feedback on supervision techniques and one-on-one guidance. The administrator comes to the facility at random hours after 5pm to observe staff and ensure line of sight supervision is being followed that includes within hearing and seeing distance. Also, staff are assigned areas to be posted in during their shit to comply with line-of-sight supervision. The case manager and education specialist observe supervision of direct care staff and staff observations with administrator. They also provide redirection and guidance relating to supervision.


summary: 748.3315 - Water-A thermostat must control the temperature of hot water accessible to children, so the temperature is no higher than 120 degrees Fahrenheit

raw_content: The bathroom sink and shower water in room 2 of the Green house was observed to with no hot water.

Correction Narrative: A walk-through of the houses were compelted and all had working hot water.  A system was put in place to complete a walk-through of the homes with a checklist to look for any physical site issues/expired foods at the start of each shift, twice a day.


summary: 748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review

raw_content: Fire extinguisher on the second floor of the green house expired in August of 2024.


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

raw_content: A child made an outcry of physical abuse to multiple staff by a staff member that was not reported.

Correction Narrative: An email was received on 11/14/2024 from the Administrator.  Staff were re-trained on serious incident reporting and the new forms that were created.  Staff involved were coached, guided and trained one-on-one.


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

raw_content: The green house was observed to have dead wasps in the light fixture.

Correction Narrative: A walk-through of Green House was completed, Gray is no longer operating; there were no bugs observed inside or outside the home.  Staff stated a walk-through is completed and work orders are put in and then the Maintenance Supervisor completes a walk-through in the morning and afternoon.


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

raw_content: It was observed that a broken dresser in Bedroom 5 of the green house has not been removed.

Correction Narrative: A walk-through of Green House was completed, Gray is no longer operating; all rooms had dressers in good condition.  Staff stated a walk-through is completed and work orders are put in and then the Maintenance Supervisor completes a walk-through in the morning and afternoon.


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

raw_content: A staff member admitted to sleeping on shift.

Correction Narrative: An email was received stating, staff were trained on the importance of staying awake and also notifying the Program Administrator immediately if someone falls asleep on their shift.


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

raw_content: A staff member admitted to hitting a child in care.

Correction Narrative: The Adminsitrator completed a training with all staff regarding the incident and appropraite ways to handle escalated situations.  Staff were spoken to and stated they did complete the training.


raw_content: The allegation is related to a DFPS abuse/neglect investigation.

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


raw_content: A child in care had a prohibited item which wasn't locked back up and resulted in another getting injured.

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

Correction Narrative: Chilrden and staff were spoken to; children stated staff staff watch them and take up contraband and staff stated they follow procedures for contraband.  Staff stated they discussed the incident and makign sure all procedures are followed.


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

raw_content: A child in care did not receive immediate medical attention after receiving burns to their arms.

Correction Narrative: Staff stated they have been informed to staff incidents with supervisors and if a child refuses to get medical care an EMS may need to be called.


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

raw_content: A staff member drove children in care around with confiscated drugs in the glovebox.

Correction Narrative: Staff stated they discussed the incident and where informed of proper procedures they are to follow in this type of incident.


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

raw_content: An incident report, dated 9/11/23, described a 12-year-old being restrained for attempting to runaway into the woods.

Correction Narrative: Corrected.


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

raw_content: While reviewing files it was found the supervision section did not include information about day to day supervision requirements in the home or supervision outside the home.

Correction Narrative: On March 11, 2024 an email was received, the Treatment Director will include more detailed information for youth's supervision needs.


summary: 748.1117(3) - Documentation of searches-Document the reason for the search in the child's record

raw_content: While reviewing search records for children's rooms/possessions it was observed that required information was missing from the reports.

Category: Children's Rights

Correction Narrative: On March 11, 2024 an email was received. A meeting was completed on February 28, 2024 which included searches and documentation.  Certificates of completed were reviewed.


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

raw_content: While reviewing the files, children did not have safety plans in place at the time of admission.

Correction Narrative: On March 11, 2024 an email was received.  The Treatment Coordinator will prepare a safety plan with each youth at intake and provide a copy for the youth's file and staff working with youth beginning March 11, 2024


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

raw_content: While reviewing files it was observed that the admission assessments did not contain all required information.

Correction Narrative: On March 11, 2024 an email was received; all administrative staff who conduct admission assessments will be retrained by March 30, 2024.


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: While reviewing the screenings it was found they were not being completed within 30 days of the last screening.


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

raw_content: During the walkthrough of the operation food was observed in refrigerator unsealed in two different units. Staff was asked to throw away several pounds of bad cheese during the walk through.

Correction Narrative: During the walkthrough of the operation there was no food observed left out or inappropriate stored.  A training was conducted regarding food storage on 3/7/2024.


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

raw_content: During the walkthrough of the operation various cleaning chemicals were observed unsecured in the kitchen drawers and under the kitchen sink.

Correction Narrative: During the walkthrough of the operationthere were no chemicals observed out.  A trainign was conducted regarding chemical storage on 3/7/2024.


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: After speaking with multiple caregivers and residence, I became aware that a caregiver was not present during the incident and the operation was out of ratio with 15 residents and 2 staff members.

Correction Narrative: Follow up inspection #3994164 Four staff and the Administrator were spoken to regarding ratio.  There are two staff above what's needed to float around.  They stated they know they are not to leave the house out of ratio for an incident; they will call for help.


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: Photos were reviewed of exposed nails and screws on a bedframe, broke outlet cover and holes in the walls.

Correction Narrative: A walk-through was completed and all beds were in good repair, outlets had covers and there weren't holes in the wall.  The Adminstrator stated the Operations Managers complete walk-through throughs at the beginning of their shifts and the Materials Manager completes walk-throughs.


raw_content: A staff member made inappropriate comments regarding a child's physical ability and inappropriate comments regarding sexuality.

Correction Narrative: Per the Adminstrator a meeting was held with staff about watching what they talk about and how they say things.  Staff were talked to and stated they have had a reent meeting about talking in front of kids and waht they talk about .


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

raw_content: 1 service plan referenced the child by a name other than their own and 3 entries on the unauthorized absence log had information pertaining to a different child than the one being discussed.

Correction Narrative: An email was received; the operation stated the Program Director will began reviewing all service plans for errors before finalizing.


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: It was found during the investigation that vehicle keys were left unsecured which resulted in children in care stealing the operation van.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: During the investigation it was found the office door, which is the second lock for medications, was left unlocked and children in care were able to access the office.

Correction Narrative: All three houses now have locked tackleboxes for each child's medication inside the locked medication cabinets.  The office door is no longer considered the second lock.


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

raw_content: Three children's service plans reviewed were missing some high risk behaviors although it is noted in other sections of the plan that the children have history of unsafe behaviors such as verbal and/or physical aggression, substance use, delinquency, threats of self-harm and harm to peers, and/or run away. There was also no documentation of known triggers for the children on the plan.

Correction Narrative: The operation provided an email reporting that the Treatment Director will include any history of a behavior as a "high risk" behavior moving forward. They reported the Treatment Director and Program Director reviewed requirements and places where this information may be found in a child's file.


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: One incident report on 10/15/23 involving a teenager in care, was called in past the 6-hour required timeframe for reporting to the A/N hotline for an unauthorized absence and Law Enforcement was not contacted. For another unauthorized absence incident involving two other children in care, on 10/14/23, law enforcement was also not contacted.

Correction Narrative: An email was received stating all shift supervisors will be retrained on AWOL reporting requirements by December 15, 2023 to ensure that all incidents are reported within the required timeframes.


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

raw_content: During the walkthrough each of the bedrooms were observed to be unclean, with beds unmade, clothing and shoes throw around the room.


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

raw_content: During the walk through of the operation, multiple bathrooms were found to have trash on the floors, urine on and around the toilets and soap on the floors.


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: During the investigation, required documentation couldn't be provided for a serious incident.

Correction Narrative: On March 9, 2024 an email was received. A meeting was completed on February 28, 2024 which included completing incident reports for all children involved.  Certificates of completed were reviewed.


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

raw_content: A portion of two door frames were observed to be broken. One of the doors was observed to have broken door handle.

Correction Narrative: Doors were observed to be fixed and those that were recently broken have work orders to be fixed.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: While reviewing 4 staff files it was discovered staff were not receiving instructor-led pre-service psychotropic medication training by a health-care professional.

Correction Narrative: Creighton Oaks is going to have a nurse conduct medication training for new employees.  Trainings will be offered one time weekly to ensure we are able to get everyone done during pre-service training.  We will also be able to have current staff renew their training with Nurse Mathews.  This will be effective September 1, 2023.  Staff members are signed up for the training on September 1 and if missed will not return to work until completed.


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

raw_content: A staff was observed sleeping by a Department staff and operation staff.

Correction Narrative: The employee involved was terminated immediately, termination letter was provided.  All staff reviewed the 24-hour awake policy and were reminded if they sleep on duty or do not report someone sleeping, it is immediate termination. There was no supervisor on duty the night staff was sleeping; a supervisor has now been put in place on all shifts.  In the event one supervisor is out a supervisor will be called in to replace them.


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: Several children were caught intentionally inhaling axe body spray. This incident was never reported by the agency to Licensing.

Correction Narrative: All supervisors are currently in weekly training and will participate in additional training on reportable incident reports.  What should be reported, who to report to and the time frame for reporting.


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

raw_content: A caregiver admitted to using inappropriate/profane language about a child in care in their presence.

Correction Narrative: On March 27, 2023 an email was received with the compliance plan.  A copy of the Staff Standards of Conduct was resent to all staff and supervisors will print and review with all staff as well.  The training instructor is currently in training this Tuesday-Friday for advanced CPI  with trauma instructor training.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: Documentation provided only listed a two-person restraint as being used, but no specifics.

Correction Narrative:
On November 22, 2022 an email was received from the Administrator stating the following: The following was sent to all supervisors concerning our deficiencies on this investigation.  We will also review this as a whole group at our next all-staff meeting.  I also met with our Quality Assurance Manager and reviewed the report and expectations for us as a facility moving forward.
The investigation involving the restraint with Blaise Lee on the night of the incident with Tyrese, has come back.  We were sited on two standards.  I am attaching a copy of the CPI holds which includes the names of the holds. A copy is also located in the staff office in the front of the form's notebook.  Please remind all staff when completing restraint forms to include the specific name of the hold they use during the incident.  Example:  seated position, lover level risk or standing position, medium level risk.  The name of the hold must be included in the restraint report.