raw_content: A staff member threatened a child in care with corporal punishment.

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


state: TX

facility_name: TLW Transformation Center

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

raw_content: Two out of three employee files reviewed did not include at least one of the following: a job description, TB skin test, drug test, affidavit for employment, nor signed acknowledgment of the operational policies and the acknowledgment of reporting abuse/neglect.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: An email was received from the operation which included the missing documents for verification.


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

raw_content: Four out of four serious incident reports reviewed didn't include at least one of the following: information about operation and time of incident.

Correction Narrative: An email was received from the operation which included the corrected documents for verification.


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 out of one youth discharged file reviewed does not include contact information for the person the youth was discharged to nor did it include the child's reaction to the discharge.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low


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

raw_content: Three out of three medication records reviewed did not include the prescribing health care physician's name.

Category: Medication


summary: 748.453(a)(4) - Unauthorized AbsenceAnnual summary log must include name of caregiver responsible for child at time absence discovered

raw_content: The unauthorized absence log reviewed did not include the staff responsible for supervision at the time of the occurrence.


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: Two out of three youth files reviewed did not include the child's understanding of the placement in the admission assessment.

Standard Risk Level: Low

Corrected at Inspection: Yes


summary: 748.911(b)(3)(A) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi/Adult CPR if serving children 0 to 17.

raw_content: One out of three employee files reviewed only contained a pediatric CPR/first-aid training certificate to indicate completion of the training and not an adult training.

Category: Training and Professional Development

Standard Risk Level: Medium High

Correction Narrative: An email was received from the operation's owner, Synithia Harvey, which included a copy of the updated CPR training certificate taken by Roxanne Cokes.


summary: 748.4553(2)(A) - Policies and Procedures- Employee protocols and procedures to include internal and external system addressing emergency situations

raw_content: Policy does not state their internal and external communication system for emergency situations.

Category: Organization and Administration

Correction Narrative: Corrected.


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

raw_content: Not in mock child file.

Deficiency Narrative: Not in mock child file.


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

raw_content: Not in child mock file.

Deficiency Narrative: Not in child mock file.


summary: 748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children

raw_content: Water throughout the facility did not get hot.

Category: Physical Site


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

Category: Children's Rights


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

raw_content: 4 of 4 staff files were reviewed and all were missing most of the information needed.

Category: Reports and Record Keeping


summary: 748.3351(3) - Interior Space-Provide 40 sq feet of indoor activity space per child, including adult residents and children of caregivers residing at the operation

raw_content: Three common areas are over capacity per the square footage allowed.


summary: 748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation

raw_content: no qualifications for caregiver in policy, no orientation for the child in the EBI policy, no EBI policy indicating informing the child and parents of EBI utilization, no training of EBI policy, no policy of not retaliating after misuse of EBI reported


summary: 748.4551(1) - Policies and Procedures- Policies must be written and describe the variety of activites offered to develop skills and independence

raw_content: Policy does not state what activities they will use for children to develop their personal identity and life skills for 14yo or older. Also does not state information about the mentor services or information about how they will prevent or discourage children from running away from the facility.


summary: 748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants

raw_content: Discipline policy doesn't indicate discipline for infants or indicates how caregivers will promptly meet the needs.


summary: 748.1823(1) - Pregnant child-health-care professional must document whether any type of emergency behavior intervention is inadvisable

raw_content: Not indicated in policy.

Category: Child Care

Deficiency Narrative: Not indicated in policy.


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

raw_content: There was no policy regarding background check.


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

raw_content: Policy does not have the job description.


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

raw_content:
All bathtubs need bleach and new caulking.
rm 220- hole in ceiling of bathroom
rm 221- hole in ceiling of bathroom
rm 222- wallpaper coming off under sink, broken tile in the shower and sink was clogged.
rm 214- wallpaper in bedroom coming off
rm 228- broken tiles in bathroom
rm 211- wallpaper coming off in bathroom
rm 210- air vent in bedroom needs screwed in


summary: 748.2755(a)(1) - Simultaneous Interventions-May use emergency medication with mechanical restraint only if allowed by operation's policies

raw_content: Not indicated in EBI policy

Category: Emergency Behavior Intervention

Deficiency Narrative: Not indicated in EBI policy


summary: 748.2751(a)(1) - Successive Interventions-Caregiver may successively use emergency behavior interventions on a child only if allowed by operation's policies


summary: 748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for  day/overnight visits, ensure policy meets requirements

raw_content: Policy does not address if staff are able to take children for overnight visitations. Policy also does not address reporting serious incidents.


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

raw_content: Volunteer policy doesn't indicate contact with children in care.


summary: 748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met

raw_content: Seventeen bedrooms was over capacity per square footage allowed.


summary: 748.117 - Transitional living policy - For operations who offer a transitional living program, you must develop policies

raw_content: No policy

Deficiency Narrative: No policy


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

raw_content: Policy does not specify required employee vaccines or exemptions. Policy also does not state how they will verify compliance or verify exemptions. Policy also does not state a procedure to protect children for exempt employees. Policy also does not state how they will maintain records or any disciplinary actions for employees who do not comply.


summary: 748.111(2) - Child-care Policy - Child's right to correspond by mail, including electronic messages

raw_content: Policy does not state electronic mail correspondence. The policy also does not address children receiving gift or any restrictions of gifts. Also does not address if staff are able to take children for overnight visitations.


summary: 748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint

raw_content: Not in mock child file.


summary: 748.1211(a)(1) - Parent Orientation - Provide fee policies

raw_content: Missing from policy.

Deficiency Narrative: Missing from policy.


summary: 748.2451(a)(1) - Emergency Behavior Intervention-Use short personal restraint only If policies permit and requirements of this subchapter are met

raw_content: Policy did not indicate restraints will be used but mentioned staff will escort youth if need be.


summary: 748.1207(a)(1) - Placement agreement-Must include authorization permitting operation to care for the child


facility_name: Alijah House Children's Services

summary: 748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223

raw_content: During the inspection, it was observed that the operation did not have current medical documentation on file for three children in care as required.

Correction Narrative:
RCCR Inspector Mariana Vega received the compliance plan and corrections via email on 1/30/2026. Medical appointments completed and documentation filed.
Prevention: Medical tracking logs and monthly reviews implemented.
Responsible Party: Case Manager / Executive Director


summary: 748.949(a) - Annual Training Documentation-Keep documentation verifying completion of training in the personnel record

raw_content: During the review of the employee files, it was noted that one employee was missing the required annual trainings.

Correction Narrative:
RCCR Inspector Mariana Vega received the compliance plan and corrections via email on 1/30/2026. Corrective Action: The employee completed all required annual trainings and documentation was placed in the personnel file.
Prevention: Quarterly personnel file audits and a training compliance checklist will be used.
Responsible Party: Executive Director
Completion Date: 05/30/2025


summary: 748.1501(b) - Dental care-The child's record must include a written record of each dental examination

raw_content: During the inspection, it was observed that the operation did not have current documentation on file for two children in care as required .

Correction Narrative:
RCCR Inspector Mariana Vega received the compliance plan and corrections via email on 1/30/2026. Dental tracking and monthly audits implemented.
Responsible Party: Case Manager / Supervisor
Completion Date: 06/05/2025


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

raw_content: The medication record indicated that there were to be twenty-one pills remaining, but the actual pill count was twenty.

Correction Narrative:
RCCR Inspector Mariana Vega received the compliance plan and corrections via email on 1/30/2026. Corrective Action: Medication count corrected and verified.
Prevention: Staff retrained, shift-to-shift verification implemented, and weekly audits conducted.
Responsible Party: Program Supervisor
Completion Date: 05/23/2025


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

raw_content: During the investigation service plans were unable to be reviewed due to the operation not providing records in a timely manner.

Correction Narrative:
The operation sent their compliance plan via email on 6/23/2025. The operation provided corrections and an updated record access protocol.
Corrective Action Steps:
1. Record Access Protocol: Implement a centralized digital record-keeping system (secured and access-controlled) to ensure all active service plans and required documents are stored in a Licensing-ready format.
2. Staff Training: Train all case management and administrative staff on procedures for responding to licensing record requests within one hour.
3. On-Site Licensing File Binder: Create and maintain an on-site binder of all current records required for immediate inspection.
4. QA Oversight: Assign Director of Compliance to conduct random monthly audits to verify file accessibility and completeness.

A staff training was conducted to ensure staff are able to respond to licensing record requests within the required timeframe.


summary: 748.1337(b)(1)(A)(v) - Initial Service Plan-Include educational needs and how needs will be met; include any school evaluations or recommendations

Deficiency Narrative: During the investigation service plans were unable to be reviewed due to the operation not providing records in a timely manner.

Correction Narrative:
The operation sent their compliance plan via email on 6/23/2025.

Corrective Action Steps:
1. High-Risk Screening: All youth will be assessed for high-risk behaviors at intake. Results will determine need for individualized safety contracts.
2. Safety Contract Template: Develop and implement a standardized safety contract template to be customized per child and signed within 72 hours of intake.
3. Training: All clinical and direct care staff will be trained on how to collaboratively develop and implement safety contracts with youth.
4. Supervisor Review: Director of Compliance will ensure the inclusion of safety contracts in all initial plans for high-risk youth before approval.


summary: 748.1337(b)(1)(H)(ii) - Initial Service Plan-child w/ high risk behaviors, include specific safety contract developed btwn child & staff to ensure safety

Standard Risk Level: High

Correction Narrative:
The operation sent their compliance plan via email on 6/23/2025.

Corrective Action Steps:
1. IEP/Educational Summary Requirement: Require inclusion of IEPs, assessments, and school records at the time of admission or within 7 days.
2. Educational Section Checklist: Add a service plan checklist item specific to academic needs, school attendance, tutoring, or special education services.
3. Collaboration with School Liaisons: Strengthen communication protocols with LEAs to ensure documentation and recommendations are up to date.
4.QA Monitoring: Director of Compliance will verify that all Initial Service Plans include required educational content before final approval.


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

raw_content: The child's file was missing the required 90-day service plans when receiving treatment services.

Correction Narrative: In response to the need for timely service plan reviews, we will establish a schedule to review service plans for children receiving treatment services every 90 days from the date of the last service plan. The review process, along with any updates made during the review, will be documented. We will distribute information to staff about the importance of timely service plan reviews, specifically for children with emotional disturbances, autism spectrum disorders, or pervasive developmental disorders. A tracking system will be utilized via the casebook calendar to ensure that all service plan reviews are completed on time and in accordance with established standards. Photos were provided


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: The child's file was missing the required signed child rights.

Correction Narrative: An email was sent with the following information. In response to the requirement to inform children of their rights, we will develop a standardized process to review the rights of children and their parents within 7 days of admission. A written document outlining these rights will be created and made accessible to all children and parents upon admission. To ensure compliance, we will implement a tracking system via the casebook calendar to verify that rights have been reviewed and documented for each child. We will develop clear guidelines for staff on how to effectively communicate children's rights and support families during the admission process. Photos were provided


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: The child's file was missing the required signatures.

Correction Narrative: To comply with the citation regarding the initial service plan, we will revise our current documentation to ensure that it includes the signatures of all service planning team members involved in its development. A meeting will be held to emphasize the importance of collaborative input in service plan development. We will implement a checklist to verify that all required signatures are obtained before finalizing the service plan. Regular reviews of service plans will be conducted to ensure compliance and necessary adjustments. Photos were provided


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

raw_content: The last health inspection was competed on 02/24/2023

Category: Safety and Emergency Practices

Correction Narrative: To address the sanitation inspection requirement, we will schedule a sanitation inspection with the local health department within the next month. A record of the inspection results and any corrective actions taken will be maintained to ensure accountability. We will also develop a routine schedule for future sanitation inspections to ensure ongoing compliance with health ordinances. We will provide resources and guidelines for staff to ensure they understand the sanitation standards and practices necessary to maintain a clean and safe environment for children. Photos were provided.


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

raw_content: The last fire inspection was conducted on 09/12/24.

Correction Narrative: To address the citation regarding fire inspections, we will schedule a fire inspection within the next month to ensure compliance with the requirement for annual inspections. Documentation of the inspection date will be maintained for future reference. Additionally, we will establish a reminder system to schedule inspections annually, ensuring they occur within the required timeframe. We will also create informational materials about fire safety protocols to raise awareness among all staff members. A photo was provided


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

raw_content: Staff member yelled and used profane language towards child in care.

Correction Narrative:
To address the citation regarding prohibited punishments, our facility will implement mandatory training for staff on positive behavior support and trauma-informed care. This training will emphasize the harms of humiliating, shaming, or ridiculing children, promoting constructive disciplinary techniques instead. Clear guidelines have been established prohibiting any form of emotional punishment, with regular supervision to ensure compliance. Violations will result in immediate corrective action, and children will be encouraged to voice concerns about staff behavior.

Follow-up Interviews were also conducted


summary: 748.311(2) - Serious Incident Documentation-Includes time and date of incident

raw_content: Serious incident report reviewed didn't include time of incident.

Correction Narrative: To correct the documentation issues noted in the citation, we will enhance our incident reporting protocols to ensure all serious incidents are documented with accurate time and date. Staff will receive training on proper documentation practices, and a standardized incident report form will be introduced. Regular audits will be conducted to ensure compliance and completeness in incident reporting, fostering accountability and improving our overall documentation process


summary: 745.8411(b)(4) - Responsibilities - Not delay or prevent inspection or investigation

raw_content: Investigator had to request the documents three different times.  Originally request 04/18/2024 and not received until 04/24/2024.

Correction Narrative:
An email was sent with the following corrective action. Alijah House is committed to rectifying the recent citation under standard 745.411(b)(4),
which emphasizes the necessity of not delaying or preventing inspections or investigations.
Our corrective action plan we will ensure that all requested documents are supplied within
24 hours of a request. If there's a need to source documents externally, we will request an
extension within the 24-hour period.
To facilitate this, we have assigned a point of contact (KhaRaven Guevara or Tony Rodgers)
to handle document requests and communicate protocols to all staV. We've established a
clear process for document retrieval and trained our staV accordingly. Additionally, a
formal protocol for extension requests is in place. If an extension is needed, we will submit
the request with 24 hours of the initial request of documents.
We will keep a detailed log of all document requests and actions taken, monitor
compliance through regular internal audits, and include standard 745.411(b)(4)
compliance in staV performance evaluations. The plan will be reviewed and adjusted semiannually
to ensure continuous adherence to the residential childcare minimum standards


summary: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work

raw_content: Interviews confirm six children were being supervised by one staff. It was reported that an additional staff on shift was in the office until the end of the incident.

Correction Narrative:
Standard 748.1005-Child/caregiver ratio-Each group must have enough caregivers for that
group who are not caring for other children or doing administrative work.
Alijah House staE will keep standard ratio for each group. Care staE will not perform any
administrative work including gathering documents needed to complete daily progress
notes if forms run out.

Follow-up is placed in Chrono.


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

raw_content: One out of three youth files reviewed did not include suicide screening documentation.

Correction Narrative:
To implement policies and procedures for conducting suicide screening during admissions for children at Alijah House, in compliance with standard rule 748.1205 sub-category(a)(14)
	Review existing admission policies and procedures to assess the inclusion of suicide screening protocols.
	Develop a comprehensive policy specifically addressing suicide screening at admissions, outlining the screening tool to be utilized and the process for administration. Research and select a validated suicide screening tool appropriate for children's admissions.
	Ensure that the selected screening tool aligns with best practices in suicide risk assessment and is sensitive to the needs of children. Provide training to admissions staff on the implementation of the suicide screening tool.
	Educate staff on recognizing signs of suicidal ideation and appropriate responses during the admissions process.
	Ensure that staff members are equipped with the knowledge and skills necessary to conduct screenings sensitively and effectively. Integrate the suicide screening process seamlessly into the existing admissions workflow.
	Determine the optimal timing and context for administering the screening tool to ensure thorough assessment while respecting the child's privacy and comfort
	Establish protocols for documenting the results of suicide screenings in the child's admission records.
	Ensure that screening documentation is thorough, accurate, and maintained in a secure and confidential manner.
	Implement mechanisms for securely storing and accessing screening records in compliance with privacy regulations. Develop a clear protocol for responding to positive suicide screens during the admissions process.
	Define roles and responsibilities for staff members involved in responding to and addressing suicidal risk.
	Establish procedures for immediate intervention, including contacting appropriate mental health professionals and ensuring the safety and well-being of the child. Implement mechanisms for ongoing monitoring and evaluation of the suicide screening process.
	Collect feedback from staff members and stakeholders regarding the effectiveness and feasibility of the screening procedures.
	Regularly review screening data and outcomes to identify trends, areas for improvement, and opportunities to enhance the process. Conduct regular audits or reviews to assess compliance with the suicide screening policy and procedures.
	Generate reports summarizing screening outcomes, response protocols, and any identified areas for improvement.
	Provide reports to relevant stakeholders, regulatory agencies, or accreditation bodies as required
By implementing this corrective action plan, Alijah House aims to ensure the effective implementation of suicide screening protocols during admissions, thereby promoting the safety and well-being of children under our care and ensuring compliance with standard rule 748.1205 sub-category(a)(14)


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: An employee was unemployed for a month and was still listed has active in the system.

Correction Narrative:
To ensure timely and accurate validation of background checks for staff members associated with children's services, including the prompt deactivation of individuals who are no longer associated with our operation.
	Steps: Review the existing policy regarding background check validation and the deactivation process for staff members.
	Revise the policy to include clear guidelines and timeframes for validating background checks and deactivating individuals no longer associated with the operation, adhering to the seven-day timeline. Implement a system for documenting background check validation activities and the status of staff members.
	Maintain accurate records of background check expiration dates, validation dates, and deactivation actions.
	Ensure that records are easily accessible and regularly reviewed for compliance. Establish a clear process for notifying relevant personnel, such as HR representatives or department heads, when a staff member leaves the organization.
	Ensure that notifications trigger the initiation of the background check validation and deactivation process within the designated timeframe. Conduct periodic audits or checks to assess the effectiveness of the background check validation and deactivation process.
	Identify any areas of non-compliance or opportunities for improvement.
	Take corrective actions as necessary to address issues and enhance the overall effectiveness of the process. Foster a culture of continuous improvement by soliciting feedback from staff members and licensing reps regarding the background check validation and deactivation process.
	Use feedback to identify areas for enhancement and implement changes as appropriate.
By implementing this corrective action plan, we aim to ensure compliance with standard rule 745.651(1) regarding background check validation and the timely deactivation of individuals who are no longer associated with our operation. This will help mitigate potential risks and maintain the integrity of our children's services programs.


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

raw_content: One out of two files reviewed did not have a HS diploma in the file. The diploma was printed out and put in the file.


raw_content: Licensing waited for over an hour for the LCCA and/or staff to arrive at the facility for the inspection.

Standard Number / Description: 745.8411(b)(4) - Responsibilities - Not delay or prevent inspection or investigation

Correction Narrative:
Correctives:To ensure that responsibilities are attended to promptly without delaying or preventing inspections or investigations by having a designated individual available at the facility or within a 30-minute response time.
Action Steps: 1. Designate On-site Staff: Identify and designate responsible staff members who will be present at the facility during operational hours and who can respond within 30 minutes during non-operational hours. 2. Establish Contact Protocols: Implement a communication system that ensures designated staff members can be reached promptly in case of inspections, investigations, or urgent matters. 3. Training and Awareness: Conduct training sessions to educate all staff about the importance of timely response to inspections or investigations, emphasizing their roles and responsibilities. 4. Rotation Schedule: Develop a rotation schedule to ensure adequate coverage at all times, including weekends, holidays, and after business hours, ensuring there's always someone available or reachable within the specified time frame. 5. Contingency Plans: Develop contingency plans for situations where designated staff members might be unavailable due to unforeseen circumstances. This may include designated alternates or clear escalation procedures. 6. Review and Adaptation: Regularly review the effectiveness of the plan and make necessary adjustments based on feedback, changes in staff, or any incidents that occur.
By implementing this corrective action plan, Alijah House Children Services can ensure compliance with the specified standard, maintaining operational readiness for inspections and investigations without delay.


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: In one out of two files reviewed did not have CPR/first aid training.

Correction Narrative:
Correctives:Objective: Ensure new caregivers obtain first-aid and CPR certification within 90 days of employment.
Action Steps
1.
Enhanced Onboarding:
a.
Update onboarding to identify caregivers without first-aid certification.
b.
Clearly communicate the certification requirement during hiring.
2.
Collaborative Training:
a.
Collaborate with certified organizations for an effective first-aid-CPR program.
b.
Ensure flexibility in scheduling and interactive sessions.
3.
Streamlined Certification:
a.
Implement an efficient certification process, utilizing digital verification.
4.
Proactive Tracking:
a.
Monitor compliance actively within the 90-day timeframe.
b.
Offer support and resources for timely certification.
5.
Integrated Orientation:
a.
Integrate certification information into a comprehensive orientation process.
6.
Centralized Recordkeeping:
a.
Establish a centralized system for accurate and accessible recordkeeping.
7.
Continuous Improvement:
a.
Collect caregiver feedback for ongoing program enhancements.
b.
Periodically evaluate and refine the training process.
By implementing these refined strategies, Alijah House Children Services can enhance the efficiency and effectiveness of the first-aid-CPR training process, ensuring that new caregivers are certified within the required 90-day timeframe. This approach supports a culture of safety and preparedness within the organization.

An updated photo of the CPR certificate/card was also attached to the email.


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

raw_content: The child in care did not take the medication as prescribed. The child has not taken the medication Amantadine 100mg since 11/28/23.

Correction Narrative:
Correctives: To ensure accurate administration of prescription medication, verify children take medications as prescribed, and maintain a timely refill process. Additionally, to address situations where refills cannot be obtained, requiring an emergency medication review by a psychiatrist, even if an appointment is scheduled for a later date, in compliance with standard rule 748.2003(B)(5).
Action Steps: 1. Medication Request Protocol: - Establish a standardized procedure for medication requests ensuring they are made within a specified time frame prior to the end of the prescription period. - Train staff to accurately communicate and document medication requests promptly. 2. Refill Management: - Initiate refills within one week of the ending prescription to allow sufficient time for processing and administration continuity. - Implement a tracking system to monitor refill status and ensure timely refills. 3. Emergency Refill Situations: - Develop a protocol for scenarios where a refill cannot be filled. - Mandate an immediate call to the prescribing psychiatrist for an emergency medication review, regardless of any previously scheduled appointments, as stipulated by standard rule 748.2003(B)(5). 4. Psychiatrist Engagement: - Educate staff about the critical importance of promptly engaging the psychiatrist in emergency refill situations. - Establish clear communication channels for emergency consultations with the psychiatrist. 5. Documentation and Reporting: - Create a comprehensive documentation process to record all medication administration, refill requests, and emergency situations requiring psychiatrist involvement. - Establish a reporting system to monitor the effectiveness of the protocol and identify potential issues. 6. Regular Review and Adaptation: - Conduct regular reviews of the protocol's effectiveness and make necessary adjustments based on feedback, changing circumstances, or encountered incidents, ensuring continuous compliance with standard rule 748.2003(B)(5).
By implementing and adhering to this protocol, Alijah House Children's Services will ensure compliance with standard rule 748.2003(B)(5) while facilitating accurate medication administration, timely refills, and appropriate emergency actions when refills cannot be obtained. This will contribute significantly to the safety and well-being of the children under care.


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

raw_content: The child's file was missing the required dental exam.

Correction Narrative:
correctives: Ensure timely and appropriate dental care for children in care, in compliance with 748.1501(a)(4).
Action Plan
1.
Immediate Assessment:

Assess each child's dental health status promptly.
2.
Clear Protocols:

Establish and communicate clear dental care protocols.
3.
Education and Communication:

Educate caregivers and staff on oral hygiene and the importance to ensue that children in care get their hygiene needs taken care of in a timely manner

Establish communication channels for dental care updates.
4.
Partnerships with Professionals:

Form partnerships with local dental professionals for check-ups.
5.
Recordkeeping and Compliance:

Implement centralized recordkeeping.

Regularly monitor and ensure compliance with dental care schedules.
6.
Continuous Training:

Provide ongoing staff training on dental health awareness.
7.
Transparent Reporting:

Establish transparent reporting to caregivers and administrators.
8.
Regular Review:

Periodically review and enhance dental care protocols.
This action plan prioritizes immediate assessment, clear protocols, and ongoing communication to ensure compliance with dental care requirements for children in care at Alijah House Children Services.

Attached with the correctives were documentation that showed the dental appointment was on 12/07/23


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

raw_content: One out of two records reviewed did not have a TB test.

Correction Narrative: Correctives: On 12/07/24 the staff had an updated TB-Skin test.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: Two out of 3 files reviewed did not have the child's immunization records.

Correction Narrative:
Correctives:Maintain current immunization records for each child in care, including exemptions or exceptions, in compliance with 748.1539(b).
Action Steps
1.
Record Review and Update:

Immediately review and update immunization records for all children in care.
2.
Documentation Protocol:

Establish a standardized documentation protocol for immunization records, ensuring completeness and accuracy.
3.
Exemption Monitoring:

Monitor and document any exemptions or exceptions to immunization requirements for individual children.
4.
Communication with Caregivers:

Communicate clearly with caregivers about the importance of providing up-to-date immunization records.
5.
Regular Audits:

Conduct regular audits of immunization records to ensure ongoing compliance.
6.
Staff Training:

Provide staff with training on the importance of maintaining current and accurate immunization records.
7.
Digital Recordkeeping:

Implement a digital recordkeeping system for easy access and efficient updates.
8.
Immediate Action on Non-Compliance:

Develop a response plan for immediate action if any child's immunization records are found to be non-compliant.
This correction action plan prioritizes record review, documentation protocols, and ongoing communication to ensure compliance with immunization standards at Alijah House Children Services.


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

raw_content: Two out of three child files reviewed had primary medical consenters that are no longer employed at the facility.

Correction Narrative:
Correctives: Ensure placement agreements include a medical consent form signed by a person legally authorized by the Texas Family Code to provide consent, in compliance with 748.1207(a)(2).
Action Steps
1.
Review and Identify Gaps:

Immediately review existing placement agreements to identify gaps in including the required medical consent form.
2.
Policy Update:

Update policies and procedures to explicitly mandate the inclusion of the medical consent form in all placement agreements.
3.
Training and Awareness:

Conduct training sessions for staff on the importance of including the medical consent form in placement agreements.

Raise awareness among staff about the legal requirements under the Texas Family Code.
4.
Template Revision:

Revise placement agreement templates to include a specific section for the medical consent form.

Ensure the language aligns with legal requirements.
5.
Legal Consultation:

Seek legal consultation to confirm the appropriateness and completeness of the medical consent form language.
6.
Communication with Authorized Individuals:

Establish clear communication channels with individuals legally authorized under the Texas Family Code to provide consent.

Provide necessary information and documentation requirements to facilitate timely consent.
7.
Recordkeeping and Audits:

Implement a robust recordkeeping system to track the inclusion of medical consent forms in placement agreements.

Conduct regular internal audits to ensure ongoing compliance.
8.
Immediate Corrections:

Develop a protocol for immediate correction if a placement agreement is identified without the required medical consent form.
9.
Ongoing Compliance Checks:

Integrate regular compliance checks into the placement agreement review process to prevent future lapses.
10.
Feedback Loop:

Establish a feedback loop for staff to report any challenges or concerns related to including the medical consent form.

Use feedback to continuously improve the implementation of the corrective action plan.
This corrective action plan emphasizes immediate review, policy updates, staff training, and ongoing compliance measures to rectify and prevent non-compliance with the placement agreement requirement at Alijah House Children Services.

Also attached were updated Attachemennt B forms.


summary: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

raw_content: One of the three files reviewed was missing the required signed affidavit.

Category: Personnel

Correction Narrative: Documents were received by email and uploaded to the document's library.


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

raw_content: The staff file was missing the required education qualifications.


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: One of the three staff files reviewed transportation certification expired.


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

raw_content: One of the three staff files reviewed did not have a current CPR certification.


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

raw_content: The operation did not complete the child's service plan withing the 45-day requirement.

Correction Narrative: The operation provided a copy of the child's completed service plan.


summary: 748.161(a)(1) - Fiscal requirements - pay employees timely

raw_content: The operation failed to properly pay their administrative.

Correction Narrative:
Corrections was sent by email from operation owner stating:

Good Evening:

Our corrected plan of action for 748.161 (a)(1) Fiscal requirements-pay employees timely are as follows:

Alijah House has contracted with Gusto Payroll and  Human Resources Corporation on February 1, 2023 to handle all payroll and human resource operations. Employees will be receiving their checks via direct deposit on the 1st and 15th of each month. This system will allow us to have proper documentation of any issues that may arise with payroll or any other personnel issues.


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

raw_content: The policy was missing the volunteers job description.


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: Missing from employee file

Deficiency Narrative: Missing from employee file

Correction Narrative:
The administrator emailed a copy of the signed affidavit.
Documents were uploaded to share-point.


summary: 748.1823(1) - Pregnant child-health-care professional must document whether any type of emergency behavior intervention is inadvisable

raw_content: There is no policy indicating the use of emergency behavior intervention regarding a pregnant child.


summary: 748.111(1) - Child-care policy - Describes visitation

raw_content: The policy does not include information about Visitation rights.


summary: 748.455(a)(1) - Unauthorized Absence  The debriefing should include the circumstances that led to the unauthorized absence

raw_content: The operation did not provide the debriefing information form that is required for unauthorized absences.

Correction Narrative: A copy of the debriefing document was emailed and met the minimum standard requirements.


summary: 748.345(1) - Electronic records policies - What records must be in external paper file and those that can be stored in electronic file

raw_content: Policy doesn't indicate which files will be electronic versus paper.

Correction Narrative: An email was sent with the missing policy details regarding electronic versus paper. The policy met minimum requirements.


summary: 745.4151(c)(2) - Drug policy includes statement of scope, including  applicability to all employees, contract employees and volunteers that have contact with children

raw_content: Indication of personnel being drug tested should also be included in the personnel policy.


summary: 748.2755(a)(1) - Simultaneous Interventions-May use emergency medication with mechanical restraint only if allowed by operation's policies

raw_content: There was not a policy that mention simultaneous interventions and the use of mechanical restraints/emergency medication.


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

raw_content: Evacuation diagram does not indicate a designated meeting area inside the home.


summary: 748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted

raw_content: The policy is missing information about Emotional Disorders in the Admissions Policy.


summary: 748.563(c) - Professional level service provider-must meet specific educational and professional qualifications

raw_content: A PLSP must be hired/designated for the operation.


summary: 748.2753(a)(1) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if allowed by operation's policies

raw_content: The policy does not mention Simultaneous Intervention.


facility_name: New Vision Mission, LLC

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

raw_content: A child s medication record for a prescription medication did not match the medication count. The medication record indicated there were 44 pills remaining while the bottle only contained 12 pills.

Correction Narrative: During the follow-up inspection all medications and medication logs were without error.


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

raw_content: During the initial inspection, it was discovered while reviewing the recreation binder that 6 of the  6 children currently placed in the operation does not have a daily indoor/outdoor recreational activity scheduled. The recreation binder included the month of February recreation.

Category: Recreation Activities

Correction Narrative: A monthly recreation calendar will be created and kept for review and posted in the general recreation areas. The supervisor will complete the calendars on a quarterly basis and file in binder and post in the designated areas.


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

raw_content: A child's medication record for a prescription medication indicated the dosage was increased to 2 pills every night beginning on 2/12/2025. The child was only administered 2 pills on that evening. The following days from 2/12/2025 to 2/24/2025, the child was administered 1 pill despite the documented medication changes.

Correction Narrative: During the follow up inspection there was no discrepancies regarding how the medication will be administered to the children in care. The medication logs coincided with the medication counts.


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 child's prescription medications were not stored in the original medication bottle. The child was discharged on 2/24/2025 from the operation, then temporarily re-admitted to the operation. During the discharge, all medication bottles were returned to the CVS worker. When the child was re-admitted, the operation staff accepted medications provided in a pill reminder box and not the original packaging.

Correction Narrative: During a follow up inspection it was noted that all medications reviewed and counted were in their original medication bottle and appropriately labeled.


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

raw_content: During the initial inspection, while reviewing the operation's recreation documents it was discovered two children in care recreation sheets had incorrect placement dates.

Correction Narrative: The mistake was corrected in the entry on the child records, indicating the correct placement date. The operation will review all recreation documents to ensure the correct placement dates are documented. Ongoing quality monitoring will be provided by the Administrator and the Compliance Officer.


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

raw_content: During the inspection, I observed all fire extinguishers mounted for emergency use were due for maintenance in January 2025,  All extinguishers were 12 days overdue for maintenance.

Correction Narrative: On 2/20/25, the operation provided photographic proof of the fire extinguishers having been retagged and indicated they were serviced on 2/14/25.  Prevention of recurrence includes scheduling inspection at least 30 days prior to the next service date and administrator noting on the calendar the date they notify the maintenance company of the need for inspection.  This brings this standard into compliance.


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

raw_content: During the inspection, I observed a child in care was arrested on 2/8/25, and the operation failed to report this incident to the hotline.

Correction Narrative: On 2/20/25, the operation provided a correction plan by email.  The incident in question was reported to the hotline on 2/10/25 following my inspection of the operation.  Preventative measures include efforts to hire a qualified Treatment Director and intention to train said Treatment Director in reporting guidelines and timeframe requirements.  The operation held a mandatory meeting on 2/16/25 to re-educate all staff on Serious Incident Reporting procedures.  A sign in sheet for the meeting was provided and uploaded to document library.  This brings this standard into compliance.


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

raw_content: During the investigation, a staff member admitted to assisting the victim child in exiting the operation without verifying the child was under continued supervision, resulting in the child with known running behaviors leaving the grounds and running away.

Correction Narrative: During the follow up, the administrator confirmed a meeting was held on 2/10/25 wherein administration issued directives to the caregivers stating children were not to be allowed outside the building without proper supervision.  The offending staff's employment was terminated on 2/10/25.  This brings this standard back into compliance.


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

raw_content: The operation failed to report the quarterly EBI data timely.

Correction Narrative: The operation sent an email stating a reminder will be added to the Administrator's calendar when EBI Quarterly report is due. Ongoing quality monitoring will be provided by the Administrator and the Compliance Officer.


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

raw_content: During the inspection, a hole was located behind the door in the unisex shower bathroom. The operation did not have a work order for this damage.

Correction Narrative: The operation staff will conduct daily facility checks on each shift. The work order to repair the hole was submitted, and the area was repaired the next day. Work orders for repairs will be submitted immediately to the Administration Team. The work order form will be revised to include the time/date the repair was found. The work order will be submitted to the maintenance crew withing 24 hours.


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

raw_content: One of the four child records reviewed was missing a parent signature on the placement agreement.

Correction Narrative: The Treatment Director and Intake Team will be in-serviced on the process for compliance. The Admissions Team will review the documents upon receipt to ensure all the required information is present. If the information is not included in the submitted documentation, the Admission Team will notify the Caseworker/Supervisor to request the missing information be provided as required. The email request for the missing information will be documented in the resident's chart. The Admissions Team will continue to follow-up until the information is received and document all correspondence in the resident's chart.


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

raw_content: During the inspection child records were requested; however, a child service plan was requested at the beginning of the inspection, 9:30 am, however, it wasn't received until 11:45 am. Although, the child's folder was provided at the beginning of the inspection, the service plan was not included.

Correction Narrative: The Treatment Director and Intake Team will be in-serviced on the process. The Admissions Team will audit the resident's files within seven days of admission to ensure all the required information is filed in the resident's file. The Treatment Director and Intake Team will be re-educated, and ongoing resident file auditing will be conducted, with ongoing quality monitoring will be provided by the Administrator and the Compliance Officer.


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

raw_content: Four of the four records reviewed did not include documentation that invites to service plan meetings were sent to the child's parent.

Correction Narrative: The Treatment Director and Intake Team will be in-serviced on the process for compliance. The Admissions Team will schedule the invites and utilize the facility's universal calendar to place the invite date and time. The email confirmation will be filed in the resident's chart. Auditing of admission charts will be performed within 7 days of admission to the facility by the Administrator or Designated Team Leader. Ongoing quality monitoring will be provided by the Administrator and the Compliance Officer.


summary: 748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care

raw_content: Two of the four child records reviewed failed to indicate the reason for the placement on the Placement Agreement.


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 of the four child records reviewed did not include a TB test exam or results for a child in care.

Correction Narrative:
The resident reviewed was sent for a TB test but was admitted to a BHC facility at the time the test was to be read. The resident was taken for the screening and the negative results was placed in the resident's chart.
The Admissions Team will audit resident files within seven days of admission to the facility. All scheduled appointments, follow-up and missed appointments will be placed on the universal calendar to generate reminders/alerts for staff. Ongoing re-education/in-services/auditing of records will be provided by the Administrator or designee. Ongoing quality monitoring will be provided by the Administrator, RN, and the Compliance Officer.
A copy of the child's TB test results was provided on 12/30/2024.


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

raw_content: In reviewing documentation, I observed a child's Initial Service Plan was completed on day 57 after admission to the operation.

Correction Narrative: On 2/10/25, the operation provided a written correction plan detailing measures taken to prevent missed service plan dates in the future.  The plan indicates the admission team enters projected due dates for the service plans in the Outlook Calendar at admission and sends out appropriate invites to the meeting.  A meeting was held on 2/7/25 by the CEO and the Administrator to review and retrain relevant staff regarding expected time frames for service plan completion.  A sign in sheet was provided.  The operation also indicated the Compliance Officer/Case Management Team/Administrator will review and audit the Initial Service Plans within 24-48 hours of completion to ensure reflected dates and times are accurate.  The operation indicates the reviewed file contained a clerical error and was completed on 11/28/24 as opposed to 12/18/24 (the date recorded on the plan).  The plan states the mistake in entry was not identified until after the RCCR review.


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

raw_content: Two of the four children interviewed reported that a staff member used profane language towards a child in care. Both children reported the same staff and child in their report of the incident.

Correction Narrative: On 1/30/2025, I conducted an inspection and spoke with three children in care regarding the standard cited. The operation conducted a mandatory training on appropriate communication, de-escalation techniques, and child interaction with the staff. A one-on-one coaching session with the staff and supervisor to review the facility policies on professional behavior and how to effectively handle challenging situations. The staff was placed on a behavior monitoring period in which the interactions between the staff and children will be closely monitored. The staff was given a formal written warning. A shift evaluation log was provided. The operation provided a sign in sheet of all participants in which all staff attended a training on 1/25/2025 on Prohibition of Abuse or Profane Language.


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

raw_content: During the walk-through, the freezer thermometer indicated the freezer was ten degrees Fahrenheit. The thermometer log on the outside of the freezer indicated the temperatures on several days was not in range.

Correction Narrative: All dietary/food handlers will be re-educated on MS 748.3443(b)(2). The dietary lead completed the work order for the refrigerator and freezer to be serviced. On 11/15/2024, the refrigerator and freezer were within the appropriate range.


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

raw_content: During the walk-through, a closet containing several chemicals was observed unlocked and accessible to children in the laundry room.


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: While reviewing employee records, one of the four records reviewed indicated three attempts were made to contact a previous employer during the same time frame each day. Documentation in the file indicated an email would be sent to the previous employer to request a reference; however, there was no documentation that an email had been sent.

Correction Narrative: The HR Manager followed up with an email on 11/14/2024 and placed the email request within the employees HR folder.


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

raw_content: During the walk-through, three of the four child medications and medication records were reviewed and indicated the pill counts were not accurate. One child s record stated 19 pills, however, the count indicated there were 18. Another child s medication record said there were 19 pills, but there were 20 pills. A third child s medication record indicated there were 44 pills and there were 46 pills.

Correction Narrative: During the follow-up inspection, three child medications and medication records were reviewed, and were found to be without error.


summary: 748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate

raw_content: During the walk-through, a child was observed lying on his mattress that was located on the floor in his room.

Correction Narrative: The mattress was placed back on the bed by the staff. The resident and staff were reminded that residents should not remove the mattress from the bed and educated on the reasons why the mattress should not be on the floor. All staff will be re-educated on this standard.


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

raw_content: During the initial inspection, four of five child medication records were reviewed and observed to be missing name and signature of person who administered the medication.

Correction Narrative: The operation held a Medication Administration training session that covered topics such as medication records, the 10 Rights for Safe Medication Administration, refusal of medication forms, and procedures for discontinuing and renewing medication. A sign-in sheet confirmed that the training took place over two days (8/28/2024 & 8/30/2024), with an hour-long session each day.


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

raw_content: Upon reviewing the children's records, it was noted that four out of five did not indicate whether the child exhibited any high-risk behaviors.

Correction Narrative:
Admission/intake staff will be re-educated on admission process that include but not limited to timely completion and filing of the documents in the resident's records, Suicide Prevention Assessment Documentation, Obtaining all required medical/preventive screenings before admission, documentation of communication with case workers to obtain required documents, policies and procedures related to intake and admissions.

Admission/intake documentation will be reviewed by the compliance officer or designee within 72 hours of admission to the facility.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: During the monitoring inspection, it was noted that three of five records reviewed were missing immunization records.

Correction Narrative:
Admission/intake staff will be re-educated on admission process that include but not limited to timely completion and filing of the documents in the resident's records, Suicide Prevention Assessment Documentation, Obtaining all required medical/preventative screenings before admission, documentation of communication with Case Worker to obtain required documents, Policies and Procedures related to intake and admissions.

The Treatment Director will continue to communicate with the Case Worker to obtain the TB screening records and document the attempted encounter along with the proof of request in the Resident's communication records.

Admission/intake documentation will be reviewed by the compliance officer or designee within 72 hours of admission to the facility. Ongoing quality monitoring will be provided by the Administrator and the compliance officer.


raw_content: Upon reviewing the children's records, it was found that four out of five children did not have a tuberculosis (TB) test on file.

Standard Number / Description: 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

Correction Narrative:
Admission/intake staff will be re-educated on admission process that include but not limited to timely completion and filing of the documents in the resident's records, Suicide Prevention Assessment Documentation, Obtaining all required medical/preventative screenings before admission and TB examinations, documentation of communication with Case Worker to obtain required documents, Policies and Procedures related to intake and admissions.

The Treatment Director will continue to communicate with the Case Worker to obtain the TB screening records and document the attempted encounter along with the proof of request in the Resident's communication records.

Admission/intake documentation will be reviewed by the compliance officer or designee within 72 hours of admission to the facility. Ongoing quality monitoring will be provided by the Administrator and the compliance officer.


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

raw_content: The review of the fire drill revealed that there was no designated meeting place established for the drill.


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

raw_content: During the initial inspection, the door to the medication closet was unlocked, making all medications (including schedule II) located inside the locked cabinet only single locked.

Correction Narrative:
The operation held a Medication Administration training session that covered topics such as medication records, the 10 Rights for Safe Medication Administration, refusal of medication forms, and procedures for discontinuing and renewing medication. A sign-in sheet confirmed that the training took place over two days (8/28/2024 & 8/30/2024), with an hour-long session each day. 8/30/2024 FD

I conducted an inspection #4020009 on 9/16/2024 and reviewed two child medication records and found them to be compliant. All doors to the medication room were locked and medications were appropriately locked in the medication room.


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

raw_content: During the initial inspection, child records were reviewed, and it was observed three of five children had missed doses of prescription medication. One child did not receive daily allergy medication for 4 days, another child did not receive vitamin D3 and prescription iron supplements for 4 days, and a third child was allowed to take half the dose of his prescription medication.

Correction Narrative:
The operation held a Medication Administration training session that covered topics such as medication records, the 10 Rights for Safe Medication Administration, refusal of medication forms, and procedures for discontinuing and renewing medication. A sign-in sheet confirmed that the training took place over two days (8/28/2024 & 8/30/2024), with an hour-long session each day. 8/30/2024 FD

I conducted an inspection #4020009 on 9/16/2024 and reviewed two child medication records and found them to be compliant.


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

raw_content: During the initial inspection, one of five child records reviewed was missing the reason medication was prescribed.


summary: 748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223

raw_content: Upon reviewing children's records, one out of five records did not have a current medical appointment.

Correction Narrative:
The operation sent an email stating the medical appointment was scheduled for UT Urgent Care. The resident refused to go to the appointment. The caseworker was notified. The appropriate documentation was completed and signed by the resident in a timely manner. Th refusal of treatment form was not filed in the resident's record at the time of the inspection.

Re-educate the staff on timely filing of resident refusal forms in the individual record with 24 hours of the refusal.

Ongoing quality inspections will be provided by the Administrator and the compliance officer. Ongoing re-education/in-services will be provided by the Administrator or designee as needed.


raw_content: During the initial inspection, five child records were reviewed. One child's record had an inaccurate medication count. The record reflected the child had 13 pills, however the medication bottle had only 11 pills.

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


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

raw_content: Upon reviewing the records of five children, it was found that none included an admission assessment.

Correction Narrative:
Admission/intake staff will be re-educated on admission admission process to include but not limited to: timely completion and filing of the documents in the resident's records, Policies and Procedures related to intake and admissions.

The files will be filed in the appropriate record by the Treatment Director/Administrator.

Admission/intake documentation will be reviewed by the compliance officer or designee within 72 hours. Ongoing quality monitoring will be provided by the Administrator and the compliance officer.


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

raw_content: Out of the five child records reviewed, three did not have the necessary suicide screenings documented.

Correction Narrative:
Admission/intake staff will be re-educated on admission process to include but not limited to: timely completion and filing of the documents in the residents records, Suicide Prevention Assessment Documentation, Policies and Procedures related to Intake and Admissions.

The Treatment Director will complete Suicide Screenings and file the documents in the appropriate record by the Treatment Director/Administrator.

Ongoing quality monitoring will be provided by the Administrator and the compliance officer.


summary: 748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care

raw_content: Upon inspection of the two first aid kits, it was found that one kit lacked a guide for the emergency contents.


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

raw_content: Upon reviewing the records of children, it was found that none of the five records had a preliminary service plan completed within 72 hours of placement.

Correction Narrative:
Admission/intake staff will be re-educated on admission process to include but not limited to: timely completion and filing of the documents in the resident's records, Suicide Prevention Assessment Documentation, 72 hour Service Plan Completion, Policies and Procedures related to intake and admission.

The administrator will review the 72 hour treatment plan to ensure accuracy. Admission/intake documentation will be reviewed by the compliance officer or designee within 72 hours of admission to the facility.

Ongoing quality monitoring will be provided by the Administrator and the compliance officer.


summary: 748.753(c)(2) - Pre-Employment Screening-You must document your diligent efforts to contact the reference, which must include more than one attempt to contact.

raw_content: One of the three records reviewed failed to document diligent efforts to contact an employment reference. The document indicates that three attempts were made dated for the same date not indicating times to verify attempts made.

Correction Narrative: All current employee files will be audited by the HR Manager to ensure the Applicant/Employee references are checked to ensure suitability to work with children. The results of the reference check will be documented on the agency's form and placed in the employee's record and include the date, time, and initials of the person making the contact. The HR Manager will be re-educated on the documentation required for compliance by the Administrator and CEO by 6/4/2024. Ongoing quality monitoring will be provided by the Administrator.


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

raw_content: Two of the three records reviewed failed to have reference checks completed by unrelated individuals. Both records included two reference checks completed by relatives.

Correction Narrative: All current employee files will be audited by the HR Manager to ensure the Employment Verification Form is completed as per the regulations. Ongoing quality monitoring will be provided by the Administrator.


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

raw_content: One of the four staff folders reviewed had a notarized Affidavit for Applicants for Employment, but the form did not indicate the individuals name that the form was being notarized for.  Another of the four staff folders reviewed did not have an Affidavit on file.

Correction Narrative: The operation provided copies of notarized Licensing Affidavit for Applicants for Employment.


summary: 748.121(3) - Abuse and neglect policy - Methods for increasing employee awareness of prevention techniques for child abuse and neglect

raw_content: The abuse and neglect policy does not include methods for increasing employee awareness of prevention techniques for child abuse and neglect.

Correction Narrative: The operation updated their policy to reflect methods for increasing employee awareness and prevention techniques for child abuse and neglect through pre-service training, refresher training, and additional training if the need arises.


summary: 748.113(8) - EBI policy - Training for emergency behavior intervention

raw_content: The EBI policy states that the operation uses CPI, however, they do not include a descriptor of the curriculum for the system.

Correction Narrative: The operation provided an updated policy including the descriptions of the CPI EBI training curriculum, and the number of hours and training required for each level employee.


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

raw_content: During the walkthrough at the standard by standards inspection, I observed the two roaches in the administration room at the facility.  One of the two roaches were alive.

Correction Narrative: The operation provided a copy of a pest control agreement indicating that services were rendered at the operation on 3/15/2024 to exterminate the property.


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: The tobacco products and E-Cigarettes policy prohibits the use of drugs, alcohol, and tobacco; however, it does not prohibit the possession of these products.

Correction Narrative: The operation updated the policy to reflect not only does the operation prohibit the use of these products by children, but also the possession of the listed products.


summary: 748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols.

raw_content: The operation created a Postvention Team, written action plan and protocols, however, they did not indicate the specific job titles of each individual included on the postvention team.

Correction Narrative: The operation updated their policy to reflect specific job titles of each individual included on the postvention team.


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: All staff folders reviewed included the name of references with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Correction Narrative: The operation provided documentation indicating contact was made to two references to verify that the applicant is suitable to work with or around children for the staff records reviewed.


summary: 748.111(8) - Child-care policy - Any religious program or activity you offer, including whether children must participate

raw_content: The child care policy does not indicate whether the operation offers any religious programs or activities, or whether children must participate.

Correction Narrative: The operation updated the policy to reflect the operation offers a voluntary non-denominational spiritual program, however, children do not have to attend. The child's religious/non-religious practices will be respected.


summary: 748.111(15) - Child-care policy - Routine health care relating to pregnancy and childbirth, if you admit or care for a pregnant child

raw_content: The child care policy does not indicate whether the operation admits or cares for a pregnant child.

Correction Narrative: The operation provided an updated policy indicating the operation does not admit or provide services for a pregnant child.


summary: 748.363(9) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: Two staff folders did not have a signed and dated form indicating that an employee must immediately report any suspected incident of child abuse, neglect and exploitation to the Texas Abuse and Neglect Hotline and to the operations administrator or designee.

Correction Narrative: The operation provided a document that was signed and dated by staff indicating they will immediately report suspected child abuse, neglect, and exploitation.


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

raw_content: Two of the four staff folders reviewed had the Pre-Employment Screening Template that indicated names of former employers with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Correction Narrative: The operation provided documentation reflecting contact was made to the employer to verify that the applicant was employed as described in the applicant's employment history.


summary: 748.363(8) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: Two of the four staff folders reviewed did not have a statement dated and signed indicating the individual has read a copy of the operational policies.

Correction Narrative: The operation provides signed and dated documents indicating the employee has read a copy of the operational policies.


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

raw_content: During the standard by standard it was observed the mock children's file did not have an initial service plan.


summary: 748.113(6) - EBI Policy - Post EBIs permitted at your operation viewable to children/clients and provide them with a personal copy of EBI policies

raw_content: The EBI policy did not include that Post EBIs permitted at the operation would be viewable to children/clients and will provide them with a personal copy of EBI policies.

Correction Narrative: The operation provided an update of the EBI policy indicating a copy of the EBI permitted will be posted on a bulletin in the hallways and will be viewable to residents.


summary: 748.113(7) - EBI policy - requirements that caregivers must attempt less restrictive and less intrusive EBI as preventive measures & de-escalating interventions

raw_content: The policy did not include a statement indicating that restraints should be used as preventive measures and de-escalating interventions to avoid EBI.

Correction Narrative: The operation updated their EBI policy to indicates the process is to use the de-escalation practices noted in the policy before using a more restrictive and intrusive behavior intervention or emergency intervention.


summary: 748.123(7) - Vaccine preventable policy - outline how you will maintain written or electronic records of employee compliance with policy

raw_content: The operation requires the forms; however, they do not indicate how they will maintain the records.

Correction Narrative: The operation updated their policy to reflect documentation will be maintained in the employees record.


summary: 748.125(d)(2) - Suicide Screening- Suicide risk screening tools must be supported by evidence-based research.

raw_content: The suicide policy did not indicated which screening tool the operation would be utilizing.

Correction Narrative: The operation updated their policy indicating they will utilize the Columbian Protocol Screening Tool, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS).


summary: 748.113(5)(A)(ix) - EBI policy - for orientation, explain and document the process for making written comments after an EBI

raw_content: The policy did not include the process for a child to make written comments after an EBI.

Correction Narrative: The operation provided an updated policy indicating the child could discuss privately, however, didn't include how the child could make written comments after an EBI. The operation was given until close of business 4/1/2024 to address these concerns.


summary: 748.125(d)(1) - Your policy must describe the suicide risk screening tool that you will use and the process for implementing the screenings.

raw_content: The operation did not indicate which suicide screening tool the operation will utilize in the policy.

Correction Narrative: The operation updated their policy to describe the suicide risk screening tool they will use and the process for implementing screenings.


summary: 748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care

raw_content:
The mock discharge summary was missing the following information required for 1439(b)(1)(A)-(F). (1) A written discharge summary, which must include]:
(A) Services provided to the child while in your care;
(B) Accomplishments of the child while in your care;
(C) An assessment of the childs remaining needs
(D) Recommendations about the services to meet the childs remaining needs;
(E) Support resources for the child, including telephone numbers and addresses; and
(F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments

Correction Narrative: The operation provided a copy of a mock discharge form that included all the sections in 748.1439 (b)(1)(A)-(F).


summary: 748.113(5)(A)(viii) - EBI policy - for orientation, explain and document to a child the way to provide voluntary comments during or after an EBI

raw_content: The policy failed to include how the operation will explain and document to a child the way to provide voluntary comments during or after an EBI.

Correction Narrative: The operation updated their policy to reflect during  orientation a child will be informed how to provide voluntary comments during or after EBI.


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

raw_content: The policy failed to state that the majority of members of the governing body must consist of persons who do not have a conflict of interest.

Correction Narrative: The operation updated the policy to reflect a statement that the majority of the members of the governing body must consist of persons who do not have a conflict of interest.


summary: 748.105(10) - Personnel Policies- Must include either the model drug testing policy or a written policy that meets or exceeds the criteria in the model policy.

raw_content: The operation does not have a formal policy regarding drug testing. The operation provided a drug and alcohol testing consent form.

Correction Narrative: The operation provided a written drug testing policy.


summary: 748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation

raw_content: The EBI policy did not include the qualifications for caregivers who assume the responsibility for EBI implementation.

Correction Narrative: The operation updated the EBI policy to reflects the trainer responsibilities and what the trainer will provide, but does not specify that these are the qualifications for the caregiver to assume responsibility for EBI implementation.


summary: 748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority

raw_content: The policy included a flow chart that shows a straight-line declination of positions, however, it does not specify the lines of responsibility and to whom each report. The written staffing pattern doesn't indicate this information either.

Correction Narrative: The operation updated the organizational flow chart that reflects which the chain of command in the operation.


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

raw_content: There is a policy related to code of conduct, however, it does not include the parameters for entering into financial relationships or transactions.

Correction Narrative: The operation provided an updated conflict of interest policy that addressing entering into financial relationships or transactions.


summary: 748.3351(4) - Interior Space-provide bedrooms with at least one window with outside exposure to natural light

raw_content: During the inspection one of the bedrooms windows had a window that was painted and did not provide natural lighting.

Correction Narrative: The operation provided a photo showing the bedroom window no longer had paint on it and was opened provided natural lighting.


summary: 748.105(9) - Personnel Policies - Must require those with access to information about a child be informed of their responsibility to maintain confidentiality.

raw_content: There is a form included in the policies for the specified individuals to sign stating they will not disclose any information regarding children in care, however, the document does not include an explanation any form of explanation that the children's confidentiality is protected by law, and it is their obligation to maintain and protect that privacy.

Correction Narrative: The operation the policy to reflect the responsibility of personnel to maintain confidentiality to a child's information.


summary: 748.121(4) - Abuse and neglect policy - Strategies for coordination between the operation and appropriate community organizations

raw_content: The abuse and neglect policy did not include strategies for coordinating between the operation and appropriate community organizations.

Correction Narrative: The operation updated their policy to reflect community organizations they will coordinate services with.


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

raw_content: During the standard by standard it was observed there was no mock preliminarily service plan.

Correction Narrative: The operation provided a copy of a mock Preliminary Service Plan form that met the requirements of 748.1331(a).


facility_name: Blessed Kidz Residential Treatment Center, LLC

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

raw_content: Staff spat on a youth face.

Deficiency Narrative: Staff spat on a youth face.

Correction Narrative: Blessed Kidz Administrator will retrain staff on acceptable forms of discipline by December 6, 2025. This training will focus on permissive means of discipline as well as prohibited uses. All staff who do not participate will be removed from the shift.


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

raw_content: Medication logs were observed to list dosages as "1 Package" rather than reflecting the accurate dosage instructions provided by the pharmacy.

Correction Narrative: 748.2151(c)(4) Blessed Kidz Administrator will ensure that the Medication record will include the medication name, strength and dosage. Staff has been trained on this standard and all medication logs reflect what this standard entails. This has been corrected.


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: Medication was observed to have been removed from its original pharmacy containers and combined into a single package, which is not consistent with how it was dispensed by the pharmacy.


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

raw_content: Operation staff did not provide adequate supervision which allowed for child to tattoo themselves.


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

raw_content: One of two serious incident reports reviewed noted no witnesses listed on the report.

Correction Narrative:
The LCCA will retrain staff on documentation and ensure that it includes names of all adults involved and their role in relation to the child(ren) and that it prints out correctly on the form. This will be accomplished by reiterating in staff meeting/training in regards to expectations as it relates to documentation. These trainings will be conducted biweekly. The training is 2 hours.

On 11/12/25, LCCA submitted copy of Staff meeting training agenda with listed employees that attended with a checkmark next to their name. A copy of this agenda was saved in each employee's record. The operation conducted the training on 10/23/25. 4 of 6 staff completed the training. Of the 2 of 6 staff that did not complete the training, one is no longer employed at the operation, and the other staff is an as needed staff.


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

raw_content: Review of 1 of 2 unauthorized absence debrief forms was partially completed. The question specific to this minimum standard was not answered and does not document the child refused to answer this question.

Correction Narrative:
The LCCA will retrain staff on the information needed to be collected during debriefing. This will insure that the debriefing includes where child went, who was with the child, child activities & any other relevant info to their health & safety. It will also include whether or not the child refused. This will be accomplished by reiterating in staff meeting/training in regards to expectations as it relates to documentation. These trainings will be conducted biweekly. The training is 2 hours.

On 11/12/25, LCCA submitted copy of Staff meeting training agenda with listed employees that attended with a checkmark next to their name. A copy of this agenda was saved in each employee's record. The operation conducted the training on 10/23/25. 4 of 6 staff completed the training. Of the 2 of 6 staff that did not complete the training, one is no longer employed at the operation, and the other staff is an as needed staff.


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

raw_content: One serious incident report reviewed improperly document there was no injury to child during an unauthorized absence however, the child did seek medical attention for foot injury during their absence. A second serious incident report reviewed incorrectly documented the child returned on August 10th however the child did not return until August 20th.

Correction Narrative:
The LCCA will retrain staff on documentation and ensue that they provide the updated version to licensing representatives and that the updated version is in the file so that the record is kept accurate and current. This will be accomplished by reiterating in staff meeting/training in regard to expectations as it relates to documentation. These trainings will be conducted biweekly. The training is 2 hours.

On 11/12/25, LCCA submitted copy of Staff meeting training agenda with listed employees that attended with a checkmark next to their name. A copy of this agenda was saved in each employee's record. The operation conducted the training on 10/23/25. 4 of 6 staff completed the training. Of the 2 of 6 staff that did not complete the training, one is no longer employed at the operation, and the other staff is an as needed staff.


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 caregiver threatened to hit a child in care.


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

raw_content: Caregivers did not intervene during a physical altercation resulting in injury to a child.


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

raw_content: Caregivers failed to seek medical treatment for a child injured during a physical altercation


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

raw_content: During the review of the employee file, it was noted that the required notarized employment affidavit was not present in the file at the time of the inspection.

Correction Narrative: The Administrator emailed an updated notarized Licensing Affidavit as a correction.


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

raw_content: There was observed to be a broken window in one of the bedrooms  that had exposed sharp glass pieces accessible from outside the operation.


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

raw_content: During the inspection of the facility the thermometer in the refrigerator's freezer displayed a temperature of 3 degrees and food should be stored at 0 degrees.

Correction Narrative: The operation responded: Blessed Kidz RTC will ensure that a working thermometer will be in the freezer at all times. The administrator will check the thermometer reading periodically to ensure the temperature is within the required reading. Completed.


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

raw_content: During the inspection of the facility the refrigerator was found to not have a thermometer present to gauge the temperature as well as both of the deep freezers present at the facility.

Correction Narrative: The operation responded: Blessed Kidz RTC will ensure that a working thermometer will be in the refrigerator at all times. The administrator will check the thermometer reading periodically to ensure the temperature is within the required reading. Completed.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: A youth in care under a special contract is supposed to have two staff members with them at all times. During operation inspections 4 children were left in the care of 1 staff member.  Interviews conducted with youth in care also confirmed occasions of being left alone in the care of only 1 staff member.

Correction Narrative: CCR completed an in-person inspection to assess Child/caregiver ratio. 4 staff and 6 youth in care were present. Currently, 1 youth in care on a specialized contract requires a 2:1 ratio. The operation is in compliance.