summary: HRC42.04412(a) - Interference with an investigation

raw_content: Operation did not allow children to be interviewed as part of an investigation.

Correction Narrative: Follow up to deficiency was conducted by inspection at the operation on 01/25/2023.  The operation allowed the HHSC representative access to the facility, records, and children in care.  The operation stated they received guidance from their attorney that HHSC would be able to conduct inspections, access records, and conduct interviews with children in care.  The operation stated that an agreement was made with DFPS Legal regarding any need for parental consent prior to child interviews.


state: TX

facility_name: Fort Behavioral Health

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

raw_content: Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.

Category: Reports and Record Keeping

Standard Risk Level: Medium Low

Corrected at Inspection: No


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

raw_content: A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.

Standard Risk Level: Medium

Correction Narrative: Inspector received an email from administrator stating that that the treatment director will begin to track the unauthorized absences. The information will then be submitted to the Director of Quality and Compliance on a monthly basis.


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

raw_content: An employee with an inactive background check was on property at the time of the inspection.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: Yes


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

raw_content: A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.

Standard Risk Level: Medium High


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

raw_content: The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.


summary: 748.153(2)(A) - Notification - At least 15 days in advance - Changes to policies and procedures required by 748.103(b)

raw_content: EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.

Category: Organization and Administration

Correction Narrative: Inspector received an email from administrator. A copy of the updated EBI policies were received on 2/20/23 for the new EBI training for SAMA.


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

raw_content: A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.


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

raw_content: 3 of 15 files did not contain background check request information.

Correction Narrative: The background check results are in the staff files.


summary: 748.363(13) - Personnel records-Include date and reason for the person's separation from the operation, if applicable

raw_content: Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.

Correction Narrative: Any staff who are no longer employed have a letter in their file documenting the date of separation and reason.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: 13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.


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

raw_content: 2 of the 15 files reviewed did not contain a record of training taken by the employee.

Correction Narrative: All staff have files with all training the staff have completed.


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: 11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: 6 caregivers did not have information to support receiving training prior to performing assigned work duties.


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

raw_content: A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.

Standard Risk Level: Low


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: 8 of 15 employee files were missing TB exams.


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

raw_content: 7 out of 15 employee records were missing job descriptions.

Correction Narrative: A copy of the job descriptions is in the staff files.


summary: 748.1339(a) - Initial Service Plan-Service planning team must develop the service plan

raw_content: A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.


summary: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

raw_content: 2 nursing staff files did not contain a license.

Correction Narrative: Licenses were obtained for the two nurses.


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

raw_content: 2 of 15 employee records did not have sign statements to abide by this rule.

Correction Narrative: The staff have sign statements to abide by this rule.


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

raw_content: A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.


summary: HRC42.04412(a) - Interference with an investigation

raw_content: The operation did not provide the videos requested by the Investigator pertaining to a particular employee.

Correction Narrative: The video related to this incident could not be provided to meet compliance as it is outside of 60 days. Videos are stored for that timeframe only. We evaluated the provision of records at this inspection as we requested video footage for an incident that occurred this week. The operation was corporative and provided video.


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 solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.


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 caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.


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

raw_content: A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.


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: Child was observed to have redness to the armpit area and seen by the facility nurse.  The medical encounter was not documented as required on an incident report.

Correction Narrative:
An inspection was conducted to the operation on 04/03/2023 to confirm the information documented was valid. Documentation was also received to corroborate the compliance plan. The following information was provided in the plan:
Incident Report form has been updated to include a prompt for staff to document all interventions that were made before, during, and after the incident. All children were discharged from the operation. Probation is in process to review all policies and procedures. A new treatment director was hired to formalize a plan for meeting the needs of children in care.


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: Concerns of abuse of a child in care by was not reported within timeframes.

Correction Narrative: An inspection was conducted to the operation on 04/03/2023 to confirm the information documented was valid. An email was previously received a compliance plan via email from  The following information was provided in the plan: As all staff have recently been trained in Reporting Child Abuse, developed an Acknowledgement for a refresher that all staff has/will sign. (see attached) This acknowledgement will be maintained at the operation and available for review upon request. All children were discharged from the operation. Probation is in process to review all policies and procedures. A new treatment director was hired to formalize a plan for meeting the needs of children in care.


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

raw_content: Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care.  The staff did not take any action to reduce risk to the children and provide a safe environment.

Correction Narrative: An inspection to the operation was conducted that reviewed practices implemented related to Probation. A new curriculum for all staff was implemented to ensure that staff members are retrained on supervision, discipline, and de-escalation. This condition was in compliance at the inspection.


raw_content: Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.

Standard Number / Description: 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

Correction Narrative: On March 3, 2023 an all staff and management training was completed to review serious incident reporting. Ongoing training will be conducted for all staff hired after this date. The trainings are logged in the Conditions binder at the operation.


raw_content: A staff member engaged in tickling, touching, and hugging of children in care without consent.  The staff member's actions were indicated to make children uncomfortable.

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: This employee was terminated on 01/13/23. On 01/18/23 an inspection to the facility was conducted. It was confirmed that the employee was not in ratio and was not being granted access to the building.


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

raw_content: The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.

Correction Narrative: Inspector received an email from administrator. The treatment director along with the PLSP will be signing off on the service plans to ensure that it addresses each child's specific needs.


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: A youth's job was threatened by a staff member as discipline.

Correction Narrative: Staff are trained on child's rights. Children and parents are informed about their rights during intake.


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: The service plan was not signed by any of the team members.

Correction Narrative: All children were discharged from the operation. Probation is in process to review all policies and procedures. A new treatment director was hired to formalize a plan for meeting the needs of children in care.


summary: 748.605(a) - Treatment director-must meet specific professional qualifications if prevalent population has intellectual disabilities or autism spectrum disorder

raw_content: An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.


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

raw_content: The annual log was provided and two children in care who ran away for the facility was not listed.

Correction Narrative: Inspector received an email from administrator stating that that the treatment director will begin to track the unauthorized absences. The information will then be submitted to the Director of Quality and Compliance on a monthly basis. Our new Manager of Record Keeping will be provide the administrator with a weekly report. If there are 0 unauthorized absences that week, the report will reflect no absences occurred.


summary: 748.607 - Treatment Director-If more than 1 treatment service provided, can have 1 treatment director if qualifications met for the most prevalent services

raw_content: 37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.


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

raw_content: A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.

Correction Narrative: As a part of the probation serious incident reporting requirements were reviewed with all staff. At the inspection today, confirmation that the training took place was completed. Technical assistance was provided as well. This standard is being evaluated as in compliance.


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

raw_content: A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.


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

raw_content: Two caregivers held a child's arms behind her back as a form of restraint.

Correction Narrative: The operation is providing new training to staff and will be using SAMA. This curriculum will teach the staff proper ways to use restraints.


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 pushed a child against a wall as a form of discipline.

Correction Narrative: Staff are trained that corporal punishment is not allowed. Any staff member who uses any corporal punishment will be terminated.


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

raw_content: A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.

Correction Narrative: The operation is providing new training to staff and will be using SAMA. This curriculum will teach the staff proper ways to use restraints and de-escalation techniques.  New policies for the updated training will be provided to HHSC by Wednesday, February 15, 2023.


summary: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

raw_content: A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.

Correction Narrative: The operation is providing new training to staff and will be using SAMA. This curriculum will teach the staff proper ways staff can assist all youth during restraints. The new policies for the updated training will be provided to HHSC by Wednesday, February 15, 2023.


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

raw_content: Children in care were allowed to have personal cell phone devices. This process was not according to policy.

Correction Narrative: Operation has changed policy and submitted to licensing to reflect that youth are no longer allowed to have cell phones while at the operation. A copy of the new policy is on the share drive


summary: 748.1217(b)(1) - Admission Assessment-At admission, must include child's legal status

raw_content: The admission assessment did not include the child's legal status.

Correction Narrative: At inspection 4 children's files were reviewed. The children's admissions assessments now indicate the child's legal status and who the legal guardian is. The operation updated forms to meet this rules requirement.


raw_content: A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.

Standard Number / Description: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

Correction Narrative: The administrator send an email stating that staff have been trained in the new EBI SAMA through a two-day training course. They took place on different days: 1/12/23 & 1/13/23, 1/19/23 & 1/20/23, 1/23/23 & 1/24/23, 1/30/23 & 2/3/23, 2/2/23 & 2/3/23. The certificates of the staff are in the case file.


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 physically fought with a child and had to be held back by another staff to stop the conflict.

Correction Narrative: The staff member was released of her duties immediately.


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

raw_content: A staff member yelled at a child in care.

Correction Narrative: The staff member was immediately released from her employment. Other staff members are being trained on proper ways to interact with youth.


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

raw_content: There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.

Correction Narrative: Follow up inspection was conducted at the operation. As part of the operations probation, all staff are completing training for serious incident documentation and supervision.


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

raw_content: There was one bathroom that had a hole in the wall.

Correction Narrative: The hole has been repaired. A photo was taken.


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

raw_content: The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.

Correction Narrative: RCCR Inspector reviewed on CLASS to confirm background checks were conducted. Inspector also spoke to Compliance Coordinator to confirm staff will not be present at the operation until BGCs are clear.


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: Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls

Correction Narrative: On 1/6/2023, an inspection was conducted where compliance was discussed with the operation. The operation then came up with a plan on 1/9/2023 and submitted it to RCCR that they will install cordless phones in each unit and allow children to make their calls in the office rather than where staff can hear.


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

raw_content: A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.


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

raw_content: Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.

Correction Narrative: Inspector met with supervisor. The operation will have a new policy. All requested will be sent to the QA person. The staff will send a follow-up request by email to ensure that all requests are in writing. They have requested that the information be noted on their main page to request documents to their QA person.


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 was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.

Correction Narrative: Inspector spoke with supervisor. The operation will ensure all children including private pay, will be taken for any and all medical care by staff. All documents will accompany the staff and child. They have spoken to staff to ensure they understand the policy and minimum standard.


summary: 748.889(a) - If you allow EBI, 75% of EBI training must focus on the identification of problem behaviors & strategies/techniques for less restrictive interventions

raw_content: The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions

Category: Training and Professional Development

Correction Narrative: The operation has re-designed the training that will be implemented for the staff. This will be properly documented in the certificate.


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

raw_content: The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.

Correction Narrative: The staff has the experience documented properly. A copy was reviewed in the staff file


summary: 748.2853(4) - EBI Documentation-Content of the post discussion, if applicable

raw_content: On 11 of 11 EBI reports reviewed there was no post restraint discussion documented

Category: Emergency Behavior Intervention

Correction Narrative: The operation will be documenting the post discussion with the child in the service plan of the child.


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

raw_content: A staff member's training records indicated that they received 37 hours of training in one day.

Correction Narrative: The staff trainings were updated to show correct days trainings were attended. These were reviewed in the staff file.


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

raw_content: The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.

Correction Narrative: The operation has created a system where all incidents concerning a restraint will be given to the director to review and file.


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

raw_content: The preservice is part of orientation.

Deficiency Narrative: The preservice is part of orientation.

Correction Narrative: The operation has training certificates for pre-service training separate from other trainings. The certificates were reviewed in the staff files.


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: Three service plans did not have signatures of the child.

Correction Narrative: The operation was placed on probation 02/2023 and ceased operating 10/2023


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 hit a child in the chest after the child had a verbal altercation with the staff member.

Correction Narrative: The staff member is no longer employed with the operation.


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

raw_content: A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.

Correction Narrative: The staff member is no longer employed with the operation. The operation will be providing new training to staff.


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: The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred

Correction Narrative: The operation sent this inspector documentation that ratio was gone over with staff during a meeting, a memo was sent out to staff, and additional staff were hired. It was also noted that the issue where a staff left the unit causing it to be out of ratio has been addressed with staff


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

raw_content: Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.

Correction Narrative: The staff have shift meeting to review children issues and staff scheduled. This ensures that there are enough staff on duty. There is also a walkie-talkie system in place for communication. The staff member is no longer employed.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content: The incident report which documented the restraint did not include he length of time the child was restrained.

Correction Narrative: Inspector conducted an inspection and the EBI form was updated to include the length of time the child was restrained. It was reviewed at the time of the inspection.


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

raw_content: Two staff performed a restraint on a child for a situation that was not considered an emergency.

Correction Narrative: Staff attended training on EBI on 8/23/22 to discuss proper techniques, holds, privacy and de-escalations. The operation also will continue to have refresher meetings every bi-weekly concerning EBI.


summary: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

raw_content: No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.


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

raw_content: Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.


raw_content: The incident reports which documented the restraint did not include the length of time the child was restrained.

Standard Number / Description: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

Correction Narrative: Inspector reviewed the updated form to include the length of time the child was restrained. A copy of the form was received.


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

raw_content: A caregiver did not assist a staff member when two youths were involved in an altercation.

Correction Narrative: The administrator send an email stating that the staff member is no longer employed with the operation. Also, training will be provided to the staff to ensure they are informed properly about EBI and proper techniques.


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 staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.

Correction Narrative: A meeting was conducted with staff concerning the policy about calling police when children run away and then contact the operation. The staff involved in the incident are no longer employed.


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 was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

Correction Narrative: Staff are no longer employed at the operation. They were immediately terminated.


summary: 748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator

raw_content: A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.

Correction Narrative: A staff meeting was conducted to review policy and discuss reporting. Staff are no longer employed at the operation.


raw_content: Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.

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

Correction Narrative: A staff meeting was conducted to review policy. Staff are no longer employed.


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

raw_content: After receiving two children into care, a staff member took two children to an unauthorized location.  She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.

Correction Narrative: A staff meeting was conducted to review policy and discuss reporting. It was also discussed that staff are not allowed to give out their own number to the youth. Youth have a number at the operation to call for their needs. Staff are no longer employed at the operation.


summary: 748.1101(b)(3)(A) - Children's rights-communicate in language or other means understandable to child; have at least one person at all times who can communicate with child

raw_content: The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.

Correction Narrative: The operation will not be accepting children that they are not able to meet the needs of and have staff who can communicate with them.


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

raw_content: A preliminary service was not completed for a child in care.

Correction Narrative: Inspector discussed with director and CEO that they have a case worker who now is reviewing the children's files to ensure all plans are completed. Also, the electronic system will have an alert for any missing information.


summary: 748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services

raw_content: A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.

Correction Narrative: Inspector was informed by director and CEO that the children have the opportunity to attend group meetings daily and individual and family therapy weekly.


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

raw_content: A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.

Correction Narrative: Administrator sent an email stating that had immediately implemented a training schedule to address, client rapport, Case worker accessibility on the unit, and staffing ratios in accordance with the minimum standards.


summary: 748.2801(1) - EBI Time Limits-Maximum length of time for short personal restraint is one minute

raw_content: A child in care was restrained longer than one minute.

Correction Narrative: The operation created a plan to implement a training schedule to address, client rapport, appropriate de-escalation, restraint training and staffing ratios in accordance with the minimum standards. They also plan to send out memos, revisiting with biweekly training and EBI being one of the topics. Administrator will continue to monitor and compliance manager will also monitor compliance.


summary: 748.989(b)(4) - Documentation of first-aid and CPR certification-Includes the trainer's name and qualifications

raw_content: Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.

Correction Narrative: The administrator sent an email with the staffs' trainings having the required information. Also, the administrator is looking for an agency willing to provide the required information in future trainings.


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

raw_content: There were three rooms with graffiti on the walls.

Category: Physical Site

Correction Narrative: RCCR Inspector received approval to accept compliance by photos from the operation. Photos of all three of the rooms were sent by the COO. All graffiti has been removed. The photos are in the case file.


summary: 748.981(c) - First-aid-CPR training-Any new caregiver not currently certified in first-aid must be trained and certified within 90 days of employment

raw_content:
One out of two staff files reviewed did not have first aid training.

The staff member received the training for first aid on 8/31/2021. The staff member is current.


summary: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

raw_content: A caregiver was providing a child with tobacco products.

Correction Narrative: Staff member is no longer employed. Other staff were trained on Fort Behavioral Policies and Procedures concerning tobacco. A new sign was posted in the adolescent side stating "No Smoking".


raw_content: A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.

Correction Narrative: Staff member is no longer employed. Other staff were trained on Therapeutic Boundaries. Supervisors meet weekly to discuss any issues or concerns with staff or youth.


summary: 748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible

raw_content: A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.

Correction Narrative: Staff member and youth are no longer at the operation. Staff were trained on Reporting Serious incident and Child Rights. Weekly meetings were conducted with supervisors to review staff concerns.


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

raw_content: Menus do not document substitutions.

Deficiency Narrative: Menus do not document substitutions.

Correction Narrative: Operation administrator emailed an updated menu which now includes alternative meal options for residents with allergies.


summary: 748.1701(b)(2) - Therapeutic or special diet - must give information regarding the diet to the child's caregivers

raw_content: Two caregivers were not informed about all of a child's food allergies.

Correction Narrative: Operation administrator emailed the new plan that he will personally notify caregivers of each individual resident diet needs by way of email, placed in the individual resident binder, at daily shift staffing, and on each daily progress note.


summary: 748.3443(a)(5) - Food Preparation-Food items must be refrigerated immediately after use & after meals, if the food requires refrigeration

raw_content: A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food.


raw_content: A child with previous aggressive behavior was able to engage in a second altercation with another child in care.

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

Correction Narrative:
Inspector conducted an inspection to the operation and observed that the staff are no longer employed. The supervisors conduct shift meetings to discuss the staff on duty and the number of youths to ensure that there are plenty of staff. The operation has purchased walkie talkie to assist the staff. They will also be implementing a plan to meet with the youth several weeks after they have  been in the program to review the youths' preferred de-escalation methods.

Extension approved due to Administrative Review per Pene B.


summary: 748.1113(c)(3) - Child Rights searches-RTC or emergency care services program may conduct routine searches if only outer clothing is removed (shoes, coats, hats)

raw_content: The operation is performing routine searches for residents that require the removal of all clothing.

Correction Narrative: Inspector conducted an inspection at the operation and spoke with CEO. The operation has updated their policy to state that resident's will no longer be required to remove any clothing other than outer clothing such as shoes, coats, gloves, hats, etc. Searches for rooms will now be conducted with the approval of a supervisor. The operation has developed a form to document the search and this will be signed by staff and the resident.


summary: 748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them

raw_content: All children in care are not allowed to shave.

Correction Narrative: Inspector conducted an inspection at the operation and spoke with CEO. The operation has reviewed the hygiene policies with staff. To ensure that staff have read and understand these policies, all staff have been required to sign an acknowledgement form. A copy of these policies are now kept on the unit for all staff to reference as needed.


summary: 748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest

raw_content: All children placed at the operation are restricted from making phone calls for the first seven days without considering the best interest of each child.

Correction Narrative: Inspector spoke with CEO to discuss that the operation's policy for resident's maintaining contact has been updated to reflect the needed changes. The operation has now implemented a policy that differentiates the resident's contact restrictions based on their level of care and program the resident is placed in.


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

raw_content: The operation has provided staff with an employee handbook that contradicts their written operational policies, and staff are not consistently following either set of procedures.

Correction Narrative: Inspector spoke with CEO during inspection that  staff have read, understand and will be following the same policies and procedures, all staff have been required to sign an acknowledgement form. A copy of the policies staff will follow are now kept on the unit for all staff to reference as needed. All staff will be trained on the specific policies required for each level of care.


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 overdosed on over-the-counter medication and did not receive proper medical attention.

Correction Narrative: An inspection was conducted. The staff member is no longer employed. The BGC is inactive. All other staff will be trained on medical care by9/17/21.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: The administrator failed to ensure that children in care received appropriate and timely medical care, that staff conducted assigned duties, and ensured the environment was safe for children in care.  The operation has had multiple concerns for supervision that have not been addressed in a manner that improves the operation compliance.

Correction Narrative: A new administrator has been hired and will begin September 7, 2021. This was discussed in the inspection. They hope to have three licensed by the end of November.


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

raw_content: The caregiver informed about the activities the youth were involved in previously did not provide the level of supervision required to ensure children's safety.

Correction Narrative: The staff member is no longer working with the youth. The rest of staff will be training in supervision no later than September 17, 2021.


summary: 748.303(a)(9)(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: Two youths ran away from the operation. There parents were not notified within 6 hours of the youths leaving the operation.

Correction Narrative: HR has updated the checklist for are trainings. All staff will be trained by 9/17/21 on reporting. There are no new placements being accepted. There are only private placements at this time.


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

raw_content: A staff failed to provide appropriate supervision  and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications.

Correction Narrative: Inspection conducted. The staff person is no longer employed. The BGC is inactive.


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

raw_content: There were multiple restrooms in the boys and girls area that had splattered paint on the walls and the floors.  In addition, the restrooms were dirty and had areas that were not clean.

Correction Narrative: An inspection was conducted at the facility. There were no major concerns noted.


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

raw_content: There were several areas of the facility that either had giraffe, holes in the walls and was not clean.

Correction Narrative:
There were several areas of the facility that either had graffiti, holes in the walls and was not clean.

The graffiti has been corrected.


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

raw_content: The assigned caregiver did not provide the level of supervision required to ensure child's safety.

Correction Narrative: Spoke with administrator. Staff were trained on 10/5/21 on the Policies and Procedures. Also, the training covered proper supervision both auditory and visual awareness during all activities. Staff will also be aware who they are responsible for. Staff member involved is no longer employed.


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

raw_content: The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together.  This resulted in two children acting inappropriately together.

Correction Narrative: Spoke with administrator. Staff were trained on 10/5/21 on the Policies and Procedures. Also, the training covered proper supervision both auditory and visual awareness during all activities. Staff member involved is no longer employed.


raw_content: A physician completed exams with youths without having another staff member observing.

Correction Narrative: Spoke to Administrator. Doctor is no longer working with youth. Youth are having exams conducted off campus at clinic until new doctor has background check cleared. The policy is that the nurse will be in the exam room with doctor during all exams.


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

raw_content: The youth were cheeking their medication and not taking it as prescribed when the staff would administer the medication.

Correction Narrative:
Inspector spoke with staff and youth. A new process for administrating medication is conducted. Youth must have one arm behind their back. The nurse has one youth at a time. The Care Coordinator is also observing. The nurse hands the medication in a small cup. The youth takes the medication and then handed a cup of water. The nurse checks the mouth with a flashlight. The youth must cough and say the "A,B,C"s. The nurse looks in the mouth with flashlight again. The Care Coordinator also checks the youth mouth. This process has improved the youth taking their medication.

The nurses will double check the youth and ensure that the medication has been taken by them.


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

raw_content: A staff member was falsifying documentation concerning visual room checks at night.

Correction Narrative:
The director/administrator will be reviewing video and observing the logs to ensure no forms are filled out ahead of time.

The administrative stated that the staff person will no longer be working in the youth program. The administrative staff will be reviewing video and conducting unannounced inspections to ensure the staff are providing adequate supervision and care. New training took place on 6/30/21 with the staff.


raw_content: The night time visual checks on the children were not being conducted properly by checking on each child in the room.

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:
RCCR Inspector conducted inspection. Staff no longer employed. Current staff had a meeting two weeks ago to discuss the concerns of supervision. Inspector interviewed two children. Discussed that new staff are more attentive.

The administrative stated that the staff person will no longer be working in the youth program. The administrative staff will be reviewing video and conducting unannounced inspections to ensure the staff are providing adequate supervision and care.


raw_content: A group of children engaged in sexually activity and used unauthorized medication, due to a caregiver not providing the appropriate level of supervision.

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

Correction Narrative:
Inspector confirmed that the staff is no longer employed at the operation. The operation has a new process for medication.

The administrative stated that the staff person will no longer be working in the youth program. The administrative staff will be reviewing video and conducting unannounced inspections to ensure the staff are providing adequate supervision and care.


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

raw_content: The Columbia-Suicide Severity Rating Scale measured a child as high risk at admissions. The child and collateral reports disclosed a history of self harm by cutting. The initial service plan does not set a criteria for supervision neither does it implement a safety plan.

Correction Narrative: The operation submitted a compliance plan on June 22 stating that 	Per minimum standards 748.1331(a), Fort Behavioral Health will identify appropriate supervision requirements, based on current policy and procedure. These include identifying harm risks at admission and subsequently thereafter per Fort Behavioral Health's suicide risk policy and procedure. These include a Columbia Risk Assessment upon admission, rounds (q5 or q15) assigned, and a completed de-escalation plan. Within 24 hours, a Joiner Risk Assessment will be completed to ensure appropriate rounds have been assigned, a safety plan completed and uploaded into their chart, and risk of harm identified on their service plan to be addressed therapeutically. Risk of harm will be assessed at least weekly, during treatment team/staffing with the multidisciplinary team, and changed accordingly. Regulations conducted a follow up inspection on 06/29/2021. Verification was completed that  two or more staff members were on every unit, which exceeded the ratio requirement. Video cameras are placed in every common area and observations for the non treatment services units were in compliance.


raw_content: A 14 year old, with a history of self harm, was left on the unit without a caregiver. This resulted in the child gaining access to a dangerous object and engaging in self harm. The injuries sustained required medical attention.

Correction Narrative: The Operation submitted a compliance plan stating that Per minimum standards 748.1101(b)(1)(B), Fort Behavioral Health management, supervisors, and Administrator will ensure clients' rights are not violated by identifying potential staffing and client risks during weekly leadership meetings, reviewing video footage weekly, and unannounced visits during randomized times.  Regulations conducted a follow up inspection on 06/29/2021. Verification was completed that  two or more staff members were on every unit, which exceeded the ratio requirement. Video cameras are placed in every common area and observations for the non treatment services units were in compliance.


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

raw_content: Fort Behavioral Health reports that there is no set criteria for monitoring children. Staff are not being designated to complete individualized supervision based on risks identified.

Correction Narrative: A new administrator has been hired. The administrator and all directors of each program will be aware of what staff are responsible for which children. It will also be in witting.


raw_content: A staff member documented that and observation of a child was completed, when it was not done.

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

Correction Narrative: New staff have been hired and trained on completing the 72 hour service plans.


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

raw_content: Facility keys were left accessible to children in care. A child used those keys to obtain a razor and then self -harmed.

Correction Narrative: A compliance plan was received from the Administrator a new policy/procedure requires that all staff maintain keys on their person. The training occurred on May 7th with all staff. Management conducts unannounced checks to verify that staff are complying to the new rule. All compliance checks will be documented in a file and made available for Regulation's review.


raw_content: Children in care were allowed to have physical inappropriate contact with each other multiple times while being supervised.

Correction Narrative:
Fort Behavioral Health will address suicidality, self-harm/injurious behaviors, hypersexuality, and potential elopement risks at time of admission and indicate in their health records effective immediately to ensure appropriate level of supervision.
	Fort Behavioral Health will continue to complete preliminary service plans within 72 hours of admission to properly assess clients' needs, strengths, abilities, and appropriate level of supervision. This is to include, but not limited to, suicidality, self-harm/injurious behaviors, hypersexuality, and potential elopement risks. Fort Behavioral Health will continue to conduct weekly treatment teams  which include clinical director, medical director, and professional level service providers  to continually assess clients and make appropriate adjustments.

Fort Behavioral Health will continue to maintain staffing ratios of 1:5. In the event of a needed change in supervision, Fort Behavioral Health will continue to follow Policy Number CTS019, which indicates the need for 1:1 ratio only when a client presents at imminent risk and is awaiting to be transferred to IP facility for further assessment


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

raw_content: An employee was working before the initial background check was submitted.

Correction Narrative:
all employees will have a background check submitted at time of hire. Fort Behavioral Health will ensure employees have a background check submitted at time of hire by verifying this through the Child Care Regulation Account website prior to their orientation start date.
o	In an emergency staffing situation, employees who do not have background checks submitted, will be identified, and submitted as soon as we are aware per minimum standards 745.621(a)(7). Fort Behavioral Health will ensure any employees working in an emergency staffing situation have a background check submitted by verifying through the Child Care Regulation website.


summary: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child

raw_content: Two children engaged in inappropriate physical contact.  The Abuse Hotline was not notified.

Correction Narrative: All current employees will be retrained on proper reporting, and this will be documented in their employee file no later than June 18th.


facility_name: Youth Reach

raw_content: During the inspection it was found that the 3 out of the 3 employee files did not have a pre-employment drug screening on file. 1 out of 3 employees files reviewed did not have the form 2985 signed by the employee. And a review of the recent discharge file had an incorrect date on the discharge paperwork.


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 the inspection it was found that 2 of the 3 employee records reviewed did not have the affidavit form 2912.


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

raw_content: During the inspection 2 out of 3 employees files reviewed did not have the previous employment verified and did not have reference checks documented.


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

raw_content: One staff record reviewed missing documentation of Trauma Informed Care training for 2024.

Correction Narrative:
Three initial trainings required yearly are Trauma Informed Care, Mandatory Reporting, and Normalcy. Training information is provided to each Youth-Reach Houston staff member via direct communication, via text, and via email.
Trauma Informed Care training information is provided to each staff member during the first week in January each year.
Training Informed Care training is to be completed in a timely manner on each care-giver's personal device.
Once completed the certificate of training is to be forwarded/give directly to the Licensed Child Care Administrator.
The Child Care Administrator will keep a digital record of all staff training.
A hard copy will be placed in the care-givers file.

Training & Communication
Weekly and monthly training sessions will be scheduled and mandatory for all staff.
Retraining will occur as needed based on inspection results or identified deficiencies.
A training log will be maintained to track staff participation and topics covered.
Scheduled future training will be set on a perpetual calendar made available to all staff.

Assigned Responsibilities
Child Care Administrator: Responsible for implementing training programs, ensuring proper handling of all medications and supplements.
On-Duty Staff: Disburse and log all medications given properly.
Volunteers and auxiliary staff cannot dispense medication/supplements.
Child Care Administrator: Final authority on policy enforcement and communication with our licensing agency.


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

raw_content: Several bottles of OTC medications were found on top of the medicine cabinet.

Category: Medication

Correction Narrative:
Medicine cabinets and keys have been moved to a secure location behind a locked door. Caregivers are the only persons allowed in the room and is clearly marked as a Red Zone' that is locked and where children are not allowed to enter without a care-giver present.

The room entry door is to remain locked when vacant.
The medicine cabinet must be locked, and the key stowed in the lock box when not in use.
Only Youth-Reach caregivers are permitted to dispense both prescription, non-prescription medications, and prescribed supplements.
Caregiver must log all medications dispensed.

Monitoring & Inspections
Weekly inspections will be conducted for medications not stowed properly.
Weekly inspections of prescription and non-prescription logs will be conducted.
Logs will be reviewed weekly by the Child Care Administrator for accuracy and completeness.
Minimum Standards will be reviewed with caregivers to ensure proper storage and disbursing of medications.

A follow-up inspection was conducted on 5/29/25. The medication cabinet was moved from the kitchen to the staff's room and was double locked during my visit.


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

raw_content: One staff record reviewed finds that staff member did not receive EBI training every 6 months as required by minimum standards.

Correction Narrative:
EBI refresher training was conducted on April 1, 2025. EBI Refresher Training is scheduled and is on the Youth-Reach Houston's Operations calendar for October 11, 2025.

Training is required for all staff involved with operations.
Staff has been notified orally and via a calendar invitation.
Periodic reminders will be given to all staff.
Training records will be updated for each staff upon completion of training.

Training & Communication
Weekly and monthly training sessions will be scheduled and mandatory for all staff.
Retraining will occur as needed based on inspection results or identified deficiencies.
A training log will be maintained to track staff participation and topics covered.
Scheduled future training will be set on a perpetual calendar made available to all staff.

Assigned Responsibilities
Child Care Administrator: Responsible for implementing training programs, ensuring proper handling of all medications and supplements.
On-Duty Staff: Disburse and log all medications given properly.
Volunteers and auxiliary staff cannot dispense medication/supplements.
Child Care Administrator: Final authority on policy enforcement and communication with our licensing agency.


summary: 748.3005 - Sanitation Inspection-Must correct deficiencies & comply with corrections, restrictions, or conditions that sanitation inspector specifies

raw_content:
The deficiencies noted on the sanitation inspection report dated 6/28/24 were not corrected as required by the inspector.
The agency is being recited for failure to respond by due date.


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

raw_content: One out of two employee files reviewed did not include a job description.

Correction Narrative: The operation stated the staff's job description has sense been placed in the file and other staff files were checked to ensure they contained the job description as well.


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: There is no documentation of server weather drills being conducted.

Category: Safety and Emergency Practices

Correction Narrative: The operation stated both smoke detector testing and fire/severe weather drills will be on the calendar and conducted periodically to coincide with the minimum standards.


raw_content: Staff list, child list, staff files, and child files contained inaccurate and incomplete information.

Correction Narrative: The operation stated the documents in question were corrected and in the future documentation will be more thoroughly checked for accuracy.


summary: 748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented

raw_content: No documentation provided to show that the smoke detectors are tested monthly.

Correction Narrative: The operation stated both smoke detector testing and fire drills will be on the calendar and conducted periodically to coincide with the minimum standards.


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

raw_content: Documentation provided indicated the operation conducted fire drills longer than the required six months from the last drill conducted.


raw_content: One staff's file reviewed did not have a trauma informed care training.

Standard Number / Description: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.


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

raw_content: A staff members background check was not made inactive in a timely manner.

Correction Narrative: The operation deactivated the background check in question. The operation stated they will ensure to deactivate background checks for non-employees in a timely manner in the future.


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

raw_content: according to medication log, medication was not recorded on log to reflect administration of pain medication due to injury.

Correction Narrative: Administrator provided updated training for all staff held on 7/11 and 7/13. Administrator also provided updated med log to include reason medication is being taken.


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

raw_content: It was observed that the operation built a new shed and items from the shed was sitting on the basketball court for a number of days.

Correction Narrative: All the items on the basketball court were stored in the shed the same afternoon as our inspection.


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

raw_content: It was observed that some food items were placed in Ziploc bags with no expiration date.

Correction Narrative: All foods, donations and left-overs primarily will be marked with two dates before going into refrigerator/freezer storage; each individual container will be marked with a received-by date and an expiry date. As our groceries are supplemented by the Houston Food Bank, opened and mealtime left-over items are good for three days. Refrigerators and freezers will be inventoried and cleaned every other day to ensure all foods stored are within the proper date range.


summary: 748.1331(b)(4) - Preliminary Service Plan-For child receiving treatment services, identify any issues or concerns child may have that could escalate child's behavior

raw_content: While observed records, there was no information observed of issues that could escalate the child's behavior.

Category: Admission, Service Planning, Discharge

Correction Narrative: All pertinent information of child's behavior noted from the initial interview through providing placement is to be documented in the Intake Study, the Preliminary Service Plan.


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

raw_content: In one bedroom, it was observed that the light fixture was wobbly. In the kitchen, it was observed that there is a loose board under the sink.


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

raw_content: One staff and one child did not have proof of a TB test.

Correction Narrative: For all files, staff, volunteer, child in placement checklist is used to ensure all required documents are in each file. TB test results have been submitted.


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

raw_content: It was observed that the tire pressure was low on two vans that transport children and one van the heat did not properly work.

Category: Transportation

Correction Narrative: The maintenance of all vehicles used by Youth-Reach Houston have been put into our Maintain X app for weekly inspection of tire pressure, fluids, wiper blades and other miscellaneous items. The van with the heat issue is in the shop and being looked into. A work order has been submitted and will be attached to this document.


raw_content: While reviewing records, it was observed that one staff did not have normalcy training.

Correction Narrative: Training was completed and submitted to Licensing. Checklist for all training provided will be marked for each staff when training is complete.


summary: 748.1433(d) - Discharge-If child not receiving tx svcs, tell him of non-emergency discharge/transfer 4 days in advance, unless LCCA or PLSP justifies not doing so

raw_content: While observing records, it was noted that a child was informed one day before discharge instead of four days.

Correction Narrative: The child in question was a flight risk. The parent was informed of the situation prior to his discharge, but we will follow the minimum standard in the future and take the risk. The operation will ensure children are notified four days prior to being discharged.


raw_content: During the walk through of the grounds it was observed that there was were significant plain-sight hazards. Those hazards were loose pile of bricks (photo taken), broken outside door frame where grounds equipment is stored (photo taken)Water damage in the weight room near air-conditioning, back of weight room building there  was visible debris such as a washing machine, roof shingles, old table, and wood boards. (photos taken)

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

Correction Narrative: The Administrator provided photos of the outside storage building door repaired and secured with a lock; storage building cleaned and organized; sheetrock repaired.


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

raw_content: During the inspection the operation water pressure was observed to be low.  The water pressure was not hot in both homes.  It was observed that only the kitchen sink had adequate pressure.

Correction Narrative: The Administrator provided photos of the water running showing the water flow and also the temperature reading of the water from a thermometer placed under the running water.


raw_content: During the inspection it was observed that the operation had two homes with expired food. stored  This is not safe and shows poorly maintained quality food control for the children in care. There were expired milk, canned goods, bread.

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

Correction Narrative: The Administrator provided a photo of the expired foods emptied out of the kitchen. The foods were loaded into in bins and placed in a vehicle to be donated. The Administrator also provided a newly created document for daily/weekly inspections of foods and drinks in the kitchen, refrigerators, and pantry.


facility_name: 1 Ce'Renity Place Inc.

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

raw_content: During the inspection, it was observed that two out of ten children had mattresses where the springs could be felt through the sheets and mattress covers. The two mattresses were replaced with new ones.


raw_content: During this investigation, it was determined that the roof had been leaking for over 3 months in various places of the operation to include the children bed bedrooms.

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

Correction Narrative: Documentation and walk through of the facility verified the roof was repaired.


summary: 748.107(1) - Conflict of interest policies - Code of conduct on the relationship between owners, employees, contractors, children, & families

raw_content: Staff did not follow the operations conflict-of-interest policies when they drove children in their personal vehicles as well as transported children personal residences and other unauthorized locations.

Correction Narrative: An email was received from the Training and Consultant Specialist on 7.15.25. It was explained the staff meeting being held Thursday, 7.17.25, would discuss conflict of interest policy in detail and have staff sign in on a separate note to go in their file.


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: 4 children interviewed reported a staff member hits the children with a green ruler.

Correction Narrative:
8/7/25-An unnounced inspection was completed on this day. 3 children and the staff were interviewed. All 3 children denied seeing staff hit anyone. Staff was able to say that they received recent training on discipline.

7/24/25-The operation provided an email with training on Conflict of Interest, Med Administration, Discipline, and Rules dated 7/17/25 for four employees by their compliance Manger. Also, Employee Development Notes for two employees.


summary: 748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly

raw_content: The wooden log barrier leading into the playground area contains exposed metal rebar and is not maintained in good condition.

Correction Narrative: The operation submitted 7 pictures showing the playground completely updated. The operation removed all branches from the playground, cut trees that were in the way of the swings, updated the wood barrier with metal rebar sticking out, and refilled the playground with pea-gravel.


summary: 748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times

raw_content: The playground did not contain the required 9 inches of loose-fill material.


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

raw_content: 1 of 2 child files did not have immunization record for review.


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

raw_content: 1 of 2 child files did not have child's rights documentation to review.

Category: Children's Rights

Correction Narrative: 2 of 2 child files did have child's rights signed by children.


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

raw_content: Downstairs bedroom lights did not work in bedroom, closet or bathroom.

Correction Narrative: Downstairs bedroom lights were observed to be working.


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

raw_content: 1 of 2 employee files did not have current job description.


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

raw_content: Van registration is expired.

Deficiency Narrative: Van registration is expired.

Correction Narrative: Van registration was observed to be in compliance.


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

raw_content: 1 of 2 child files did not have service plan for review.


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

raw_content: Bathroom drawer was observed to be broken with exposed nails


summary: 748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing

raw_content: There were several children that did not have adequate clothing.


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

raw_content: Caregivers were using profane language in front and towards the children in care.


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

raw_content: The caregivers yelled at the children in care.


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

raw_content: There was medication that was on the kitchen table not locked up.

Correction Narrative: This was corrected at inspection, a follow-up was conducted on 2/21/23, the operation provided the caregiver with additional medication training, the training was sent via-email.


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

raw_content: A caregiver did not provide appropriate supervision to a child in care.

Correction Narrative: The Compliance Manager will Inservice Ce'Renity Place staff in regard to this standard to ensure that children will not be left alone with a provider and anyone else that is unauthorized to be a caregiver for Ce'Renity Place children.


summary: 748.1481(a) - Release of Child-Except in emergency, only release child to parent, parent's designee, law enforcement, or person authorized by law to take child

raw_content: An operation left a child for at least 45 minutes with unauthorized person.


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

Deficiency Narrative: An operation left a child for at least 45 minutes with unauthorized person.


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

raw_content: There was a window on the outside shed that was broken and there was glass on the ground.  The gate to the pool pump was broken and the entire panel was not attached.  There were slats on the fence that were broken.


raw_content: A caregiver used profane language towards children in care.

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

Correction Narrative: Follow up investigation was completed RCCR Rashida Pruitt spoke with one staff member who reported no concerns and I spoke to two children in care who denied any inappropriate discipline.


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

raw_content: A caregiver pushed a child to the ground.


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

raw_content: A staff member called a child in care a inappropriately name.


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

raw_content: One window had blinds that were broken and hanging off the cords.

Correction Narrative: Photo received from the agency showing the blinds have been replaced with a new set.


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

raw_content: It was noted that one sink in an upstairs restroom did not have hot water during an inspection.

Correction Narrative: A follow-up inspection was conducted on 9/1/2021 at the operation and all water facets were tested and had working hot water.


raw_content: The Operation had missing floor panels during an inspection.

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

Correction Narrative: A follow-up inspection was conducted on 9/1/2021 at the operation and wood flooring had not been repaired yet. The operation director reported workers have been to the home to fix the floor but new flooring had to be ordered and has not arrived yet. Documentation was provided verifying this information so an extension has been granted to give more time to fix the floor.


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

raw_content: The medication room was not locked during an inspection.

Correction Narrative: A follow-up inspection was conducted on 9/1/2021 at the operation and medication was observed to be locked and stored appropriately.


summary: 748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged

raw_content: One discharge summary reviewed did not document the information for the person the child was released to.

Correction Narrative: Email received from the agency containing a compliance plan which stated the case manager will review all discharge summaries after completion to ensure all information is documented and is accurate.


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

raw_content:
One refridgerator did not have a thermometer and two freezers were above 0 degrees Fahrenheit.

Operation came into compliance during inspection by placing a thermometer in the refrigerator and turning down the temperature in the freezers.


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

raw_content: Multiple discharge summaries reviewed did not document why the child was being discharged.


summary: 748.1437(2) - Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer

raw_content: Several discharge summaries reviewed did not document the date the child was informed of the discharge.


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

raw_content: Three beds currently being used did not have a pillowcase on the pillows.


summary: 748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days

raw_content: One of the child records reviewed did not have the placement extension done timely. The extension was done 28 days instead of 15 days.

Correction Narrative: The case manager will complete placement extensions by day 15 from the child's admission


summary: 748.4203 - Admission-Each child receiving emergency care services must receive a health screening or EPSDT examination within 72 hours after admission

raw_content: two of the seven child files shows that the child was admitted on 2/5/21 but did not receive the required medical visit until 2/9/21.

Correction Narrative: The case manager will ensure that the 72 hour medical examinations are completed in a timely manner


summary: 748.161(b) - Fiscal requirements - Maintain complete financial records that comply with Generally Accepted Accounting Principles

raw_content: One file contained a  trust fund form stating that money less than five dollars would be transferred to a Patient Benefit Fund.

Correction Narrative: The form regarding the any money less than $5 has been deleted from their use.


facility_name: A New Day Foundation

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 the monitoring inspection, four records were reviewed and all four records were missing the pre-employment affidavit for applicants for employment.

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: All identified employees have now completed the required Pre-Employment Affidavit (Form 2936). New Day Foundation has implemented a double-check review process of all employee personnel folders prior to hire to ensure the Licensing Affidavit (Form 2936) is fully completed before the employees first day of work. The Program Administrator will verify that all required pre-employment documentation is complete and compliant prior to finalizing employment.

The Pre-Employment Affidavit (Form 2936) will be incorporated into the standard employee onboarding documentation package to ensure completion prior to the start of employment.


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

raw_content: Four records were reviewed and all were missing personal reference checks.

Category: Personnel

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: Two (2) references for each affected employee have now been contacted and verified. Documentation of reference checks has been completed and placed in each personnel file.

Reference checks are now required and documented prior to employment approval. No applicant will be cleared for hire without completed reference verification.


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

raw_content: Of the four records reviewed, one was missing a statement signed and dated by the employee documenting that the employee has read a copy of the operational policies.

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: The missing signed statement has been obtained and placed in the employees file.

All new hires are now required to sign and date acknowledgment of operational policies during onboarding. Documentation is verified before file completion.


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

raw_content: Of the four records reviewed, one was missing the required notarized affidavit for employment.

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: The identified employee has completed the Licensing Affidavit for Applicants for Employment. The affidavit has been properly notarized and placed in the employees personnel file. The personnel file has been reviewed to ensure all required documentation is now complete.

New Day Foundation will implement a double-check review process of all employee personnel folders prior to hire to ensure the Licensing Affidavit for Applicants for Employment is fully completed and notarized before the employees first day of work. The Program Administrator will verify that all required pre-employment documentation is complete and compliant prior to finalizing employment. The Program Administrator and designated staff will conduct routine audits of personnel records to ensure continued compliance. No personnel file will be considered complete without a notarized Licensing Affidavit on file.


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

raw_content: The operation's Serious Incident Report forms did not include the child's age, gender, or  date of  admission as required by Minimum Standards.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: The operation's evacuation diagrams does not have a designated "shelter in place" location.

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: All evacuation diagrams have been updated to clearly identify a designated shelter-in-place location. Updated diagrams have been posted throughout the facility.

Emergency preparedness plans have been reviewed and updated.


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 most recent severe weather drill was completed in April 2025 and not within the last 6 months.

Correction Narrative:
On 4/6/2026, the Administrator provided corrections via email: A severe weather drill has been conducted immediately upon identification of the deficiency. Documentation of the drill has been completed and filed.

A drill tracking log has been implemented. Scheduled reminders are now in place to ensure drills occur every six (6) months. Administrative oversight will ensure compliance.


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

raw_content: During the inspection, I observed one of four child medication records reflected an inaccurate count of 17 pills on the med sheet and 16.5 pills in the blister pack.

Correction Narrative: The operation submitted a corrective action plan stating the counts on the med log were corrected, caregivers were reminded to make sure their pill counts were accurate and to conduct proper verifications at shift change.  He also noted a weekly medication audit will be conducted by the Case Manager or administrative staff.  The will also continue regular training procedures.  As this was a simple math error on the sheet, this correction is sufficient to bring the standard into compliance and prevent recurrence.


raw_content: During the inspection, I observed the thermometer in the refrigerator read 60 degrees and was loose in its housing.  The thermometer housing for the freezer contained the gradient grid but not the thermometer itself.

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

Correction Narrative: The operation submitted a correction plan stating the thermometers in the refrigeration units have been replaced and the units were adjusted to maintain temperatures within acceptable levels.  The program leadership and administrative staff will conduct periodic checks to ensure compliance.    Replacing the thermometers brings the standard back into compliance and the routine monitoring by administration will help prevent recurrence.  The operation also purchased a new refrigeration unit due the old one not maintaining a good seal.  Photos were submitted and uploaded of the new unit with thermometers installed.


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

raw_content: During the inspection, I observed one of four children's records reviewed contained a medication log lacking the reason for the prescription.

Correction Narrative: The operation submitted a correction plan stating the medication record was updated to include the missing information and an audit was conducted on all medication records to ensure accuracy.  The plan indicates future medication changes and new orders will include the reason for prescription prior to administration.  The operation will also maintain routine training procedures.  This citation appeared to be due to a careless transcription error, and this correction is sufficient to bring the standard into compliance and prevent recurrence.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: In reviewing the case documentation, it is evident staff utilized an unapproved restraint procedure in picking a child up by the waist to carry the child to the van.

Correction Narrative: On 1/13/26, the operation provided a written correction plan indicating the staff in question was prohibited from completing EBI's through the completion of the investigation and received additional EBI training on 1/12/26.  Sign in sheet from the training was included.


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

raw_content: In reviewing the investigation documentation, it is evident the staff utilized restraint as a method of getting the child to comply with exiting to the van.

Correction Narrative: On 1/13/26, the operation provided a written correction plan indicating the staff in question was prohibited from completing EBI's through the completion of the investigation and received additional EBI training on 1/12/26.  Sign in sheet from the training was included. Training instructed staff to prioritize de-escalation, redirection, and trauma informed interventions.


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

raw_content: In reviewing the investigation, it is evident the childs refusal to exit the building did not constitute an emergent situation requiring restraint.

Correction Narrative: On 1/13/26, the operation provided a written correction plan indicating the staff in question was prohibited from completing EBI's through the completion of the investigation and received additional EBI training on 1/12/26.  Sign in sheet from the training was included. The curriculum included refresher on the regulatory definition of an emergency situation by minimum standards.  Supervisory consultation requirements were also reinforced.


summary: 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

raw_content: In reviewing the case documentation, it was discerned a staff member restrained a child without first exhausting less restrictive behavior interventions.

Correction Narrative: On 1/13/26, the operation provided a written correction plan indicating the staff in question was prohibited from completing EBI's through the completion of the investigation and received additional EBI training on 1/12/26.  Sign in sheet from the training was included. Instruction focused on verbal de-escalation techniques, use of least restrictive alternatives, and required documentation prior to any physical intervention.  The plan also indicates the staff will be under increased supervisory oversight.


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

Correction Narrative:
There is sufficient evidence to show that staff have been yelling at the children.

Children were interviewed regarding discipline practices and there were no concerns noted.


summary: 748.2307(11) - Other Prohibited Punishments-requiring child to be silent or inactive for inappropriate periods of time for child's age

raw_content: During the course of the investigation it was determined that children in care has time out for up to 2 hours.

Correction Narrative: On 5/13/24, 3 children were interviewed regarding discipline at the operation. When asked about standing on the wall, the children stated that this no longer happens at the facility.


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

raw_content: A staff member referenced to a child in care by an unnecessary name when the child was escalated.

Correction Narrative:
On 04/15/2024 an action plan letter was received stating the staff involved was immediately suspended pending the investigation then was reinstated with conditions of training, closed supervision, changes of responsibilities, and change of shift. All caregivers will be reminded of their obligation to treat our children with dignity, respect, and professionalism at all times.

On 4/30/24 children were interviewed regarding staff interactions. The children stated that they are not called out of their names or taunted by staff members. No concerns were found during the interviews, and no children made outcries.