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

raw_content: It was determined that two caregivers do not have CPR certification.


state: TX

facility_name: Tree of Life RTC

summary: 748.4653(a)(1) - Pre-Service Training- All caregivers must receive 8 hours of general pre-service training before being only caregiver responsible for a child in care

raw_content: There is no documentation regarding pre-service training for one of two employee records reviewed.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No


summary: 748.885(3) - General pre-service training curriculum-Includes techniques and methods of administering medications if caregiver administers psychotropic meds

raw_content: There was no documentation of a training for the administering of medication.

Standard Risk Level: Medium High


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

raw_content: One of two records reviewed did not contain a notarized affidavit.


summary: 748.981(b)(1) - First-aid-CPR training-At all times, at least one caregiver counted in child/caregiver ratio must have current certification in CPR

raw_content: It was observed that two children in care was left with a caregiver/case manager that has an expired CPR certificate.


summary: 748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position

raw_content: One of two records reviewed did not contain a job description.


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

raw_content: There was no documentation about the severe weather drills.

Category: Safety and Emergency Practices

Standard Risk Level: Medium Low


summary: 748.1209(c)(1) - Child Orientation - Include information on how to make complaints to outside agencies

raw_content: Two of two records reviewed did not contain how to make complaints to outside agencies.

Category: Admission, Service Planning, Discharge

Correction Narrative: An email was provided with a signed form by the employees on how to make complaints to outside agencies.


summary: 748.1217(b)(11) - Admission Assessment-At admission, must include services the operation plans to provide to the child

raw_content: Two of two records reviewed did not contain the services the operation plans to provide for the child.

Correction Narrative: Provided an email with an updated admission assessment including the services the operation plans to provide.


summary: 748.1217(b)(14) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: Two of two records reviewed did not contain the child's understanding of being in placement.

Standard Risk Level: Low

Correction Narrative: The operation emailed an updated admission assessment that included the child's understanding of the placement.


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

raw_content: During the inspection, it was observed that the home should be sanitized before accepting children.

Category: Physical Site

Correction Narrative: The agency stated that they will ensure that the home is cleaned before admitting children.


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

raw_content: During the inspection, it was observed that over five windows do not have screens to protect against insects/bugs.

Correction Narrative: The agency provided a work order stating that the windows will have screens before they admit children in the facility.


summary: 748.831(a) - Orientation-Each caregiver or employee must have orientation prior to beginning job duties or having contact with children in care

raw_content: Three of three records did not contain orientation.

Category: Training and Professional Development

Correction Narrative: The agency provided a date for when the orientation will be completed. I will follow-up again with the agency.


summary: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: Three of three employee records did not contain a signed/dated statement of the operational policies.

Correction Narrative: The agency provided a signed copy of the policies.


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

raw_content: The policies and procedures contained conflicting information regarding whether the operation will allow staff to take children away from the operation on overnight visits. The preservice training policy (page 29) includes the name of another operation.

Category: Organization and Administration

Correction Narrative: The error of additional naming has been removed from the policies. Tree of Life RTC has updated policies stating that overnight visits will not be allowed.


raw_content: It was determined that four employee records did not consist the operational policies.

Standard Number / Description: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

Category: Reports and Record Keeping

Correction Narrative: All staff members files have been audited to ensure that no job description forms are missing, and reflect all the duties of that employee.


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: One child record observed did not have a copy of their rights.

Category: Children's Rights

Correction Narrative: Each client file will be audited to ensure that there is a signed copy of a child's rights form in every file.


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

raw_content: After reviewing the medication log I observed that there was not a space for the reason the medication was prescribed.

Category: Medication

Correction Narrative: The operation has since corrected the medication record with a space informing the reason the medication was prescribed to the client.


raw_content: During a walkthrough of the operation I observed a window on the outside of the back porch has a screen that appeared to be torn and coming open.

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

Correction Narrative:
The operation has secured all physical site deficiencies back in full tact and everything is now fully
 structurally sound.


summary: 748.3233(b)(1) - Evacuation-Emergency evacuation & relocation diagram must include a floor plan of the operation

raw_content: The floor plan used for the emergency evacuation and relocation diagram does not match the layout of the home.

Correction Narrative: Tree of Lifes floor plan has since been fully corrected in where it matches the current floor plan of the home.


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

raw_content: During a walk through of the facility I observed exposed wires near the shed in the back yard.  The floor paneling from kitchen to bedroom is loose and lifts up.  The dresser in one of the bedrooms was missing a door knob and appears to have unfinished paneling at the top. The hanging rods inside the closets are loose and can be removed. The upstairs bathroom has a hole on the side of the vanity where the toilet paper holder was located. The bathroom downstairs has a door for piping that does not shut well and is hanging.

Standard Risk Level: High

Correction Narrative: The operation has secured all physical site deficiencies back in full tact and everything is now fully structurally sound.


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child

raw_content: The assessment does not specify how to meet the needs of child's history of drug abuse.

Correction Narrative: Parent's expectations for placement and  involvement will be included by the treatment director, for each child's service planning.


summary: 748.1217(b)(13) - Admission Assessment-At admission, must include parent's expectations for placement, duration of placement, & family involvement

raw_content: The assessment does not specify how or if the childs family will be involved.


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

raw_content: After reviewing the medication log space I observed that the log was missing the prescribing health care professional.

Correction Narrative: Tree of Life's RTC Medication log now includes the prescribing health care professionals name.


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

raw_content: After reviewing the personnel records one of the staff did not have their high school diploma or transcripts in their file.

Correction Narrative: Each staff file will be audited to ensure that there is a copy of each employees diploma or transcripts.


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

raw_content: One of the staff members personnel records was missing a job description.


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

raw_content: The menu does not contain any substitutes.

Category: Child Care

Correction Narrative: Tree of Lifes menu now reflects the food substitution that is going to be offered that day,


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: The orientation was missing from the child's record.

Correction Narrative: Each client file has been audited to ensure that each client has an orientation form.


summary: 748.3233(b)(4) - Evacuation-Emergency evacuation & relocation diagram must include at least two exit routes

raw_content: The emergency evacuation plan and relocation plan shows one exit route through the laundry room, but there is not a door in the laundry room to be able to exit the home.

Correction Narrative:
Corrective Action Plan
Tree of Lifes floor plan has since been fully corrected in where it matches the current floor plan of the home.


summary: 748.1217(b)(14) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: The assessment does not specify about the childs understanding of placement.


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

raw_content: The severe weather drill form did not include a spot to document the length of time for the evacuation or relocation to take place.

Correction Narrative: The Severe weather drill has a spot to notate the length of time for evacuation.


facility_name: Divine Children's Care Home

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

raw_content: One of the two reviewed employee files revealed that one employee had not completed the emergency intervention training required every six months, and the most recent training was completed over a year ago.

Correction Narrative: Administrator provided the training certificate for the employee via email as well as put in place a process to ensure employees are aware of when trainings need to be completed by.


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

raw_content: In reviewing the personnel records, there was no proof of education for all three staff.


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

raw_content: Child files reviewed were missing the required signatures on the service plan.


summary: 745.4151(c)(5)(A) - Drug testing procedures-All drug testing will at a minimum screen for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP)

raw_content: Drug test results did not specify what the employee was screened.

Correction Narrative: Drug test results did not specify what the employee was screened for.


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

raw_content: The operations recreation schedule did not provide the required outdoor daily activities.

Category: Recreation Activities


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

raw_content: It was observed in Room 1, a hole in the door. Work order was submitted.


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

raw_content: Record indicates employee received Orientation, 40 hours of pre-service training, and 8 hours of EBI training all in one day.


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: Agency policy addresses HIPAA rules only. All child information must be kept confidential and accessible only to authorized personnel


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

raw_content: Missing Pre-Employment Affidavit for Applicants


summary: 748.4651(a) - Pre-Service Training- If operation provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: Record shows staff received 40 hours of pre-service training in one day.


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

raw_content: Record shows employee received pre-service training on 7/15/23, with TB test results received on 7/21/13, after contact with children in care


summary: 748.915(b)(1) - Pediatric CPR training documentation must include the participant's name.

raw_content: It was observed that no require training for one staff.


raw_content: Two service plans had unclear information regarding the staff's responsibilities if and when a resident goes AWOL. The AWOL annual summary log listed "NA" for the hotline intake report number and Police report number despite both being applicable.

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

Correction Narrative:
DIVINE CHILDREN'S CARE HOME is not a secured facility. Due to his age DIVINE CHILDREN'S CARE HOME staff does not have the authority to prevent Thomas from AWOL.  However, he shall continue to receive encouragement to remain at his assigned facility by way of: verbal direction, redirection, and verbal de-escalation methods.

In addition, the intake number and Waller Police Department number are both added to the AWOL log.

Waller Police Department # 24-00132
Intake Confirmation # 7876667


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

raw_content: Operation failed to report a child unathorized absent to lisencing.

Correction Narrative: Will ensure this step is completed in the future. Reports made to Waller PD however failed to report to hotline.


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

raw_content: Medication records were missing information when the medication was administered and by whom it was administered.

Correction Narrative: Staff has been informed of proper and accurate medication documentation. 6 Rights of Medication Administration is posted at the medication station, email communication sent out to staff, and staff attended Medication Administration/ Documentation Training with ACH.


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

raw_content: Operation runaway log did not have the information needed.

Correction Narrative: absence without leave log has been updated.


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

raw_content: A childs discharge did not have the infomartion address, phone to whom he was release to.

Correction Narrative: Discharge information has been updated to include the address and phone number of where the youth was released to.


summary: 748.2051(3) - Medication Self-Administration-Must consult health-care professional who prescribed medication and document his/her concerns in child's record

raw_content: A child is self administrating medication however the child records did not have documentation from the doctor, or parent that he is allowed to administered this medication .

Correction Narrative: self-administration form had been requested by primary care provider however never received. Received on 11/8/2023.


raw_content: Multiple records at the operation were not true and accurate and had contradicting information.

Correction Narrative: Will reinforce the importance of documentation with staff during our monthly team meeting. Will ensure that incident reports and documentation data are comparable.


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

raw_content: A child's discharge did not document when he was informed of the non-emergency discharge.

Correction Narrative: Operation created a new form that included all areas required by standards. The operation will use new form that provides the information of when a child is notified and if it's an emergency discharger.


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

raw_content: child preliminary service plan was not completed.

Correction Narrative: Update to child preliminary service plan was completed. Operation understands the time frames and will ensure they are completed within 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

raw_content: A child service plan did not document appropriated school goals.

Correction Narrative: Update to child service plan was completed addressing school goals, individual supervision goals. Operation created a new form that included all areas required by standards.


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

raw_content: Two out of two records were missing instructor led training regarding administration of psychotropic medication.

Correction Narrative: All staff will obtain an additional instructor led psychotropic medication training to all staff administering medication. Each employee was required to take a post exam and received a certificate of completion.


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

raw_content: Childs discharge documentation records did not have the time or the person whom he was discharge to.

Correction Narrative: Follow up was completed via email. Information was added for further discharges.


summary: 748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years

raw_content: Medication log was missing information regarding the reason for the medication, signatures of caregiver and side effects.

Correction Narrative: Follow up via email showed signature page of the staff. Follow up in person on 5/10/2023 showed that the operation has develop a new form incorporating all information listed in minimal standards.


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: One child record did not have high risk behaviors identified and how the operation will implement the safety of the chilld.

Correction Narrative: Follow up documentation showed new admission assessment incorporating all information for future admissions.


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

raw_content: The operation's search document form does not include fields or prompts for the reason for the search, what was searched, the results of the search, or the resolution of the search.

Correction Narrative: Updated copy of search document was received and complied with standard. Form included the reason for the search, what was searched, the results of the search, or the resolution of the search.


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: Employee record did not have a notarized  employment affidavit in their file.

Correction Narrative: A copy of the notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059 was put in the staff folders.


summary: 748.4111(a) - Transportation records-Must maintain on file at the operation the name of each driver and a copy of that person's valid driver's license

raw_content: Employee file did not have a copy of its driver s license in the personnel file.

Category: Transportation

Correction Narrative: Copies of driving record and driver's license were placed in the employee record.


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

raw_content: The operation did not have an Admission Assessment form developed in their record. Admission Assessment  must be completed prior to a nonemergency admission.

Correction Narrative: Admission assessment was created and reviewed.


summary: 748.1209(b)(1) - Child Orientation-Include policies on visitation, including family visitation & overnight visitation

raw_content: The orientation documentation does not include information regarding the operation's policies regarding family visitations, gifts, or the education program.

Correction Narrative: Policies were updated to address family visitations, gifts, or the education program.


summary: 748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.

raw_content: The operation's policy and procedures regarding records and record keeping does not specify a records retention timeframe.  Additionally the policy and procedure indicates records will be provided to the managing conservator and/or guardian upon request.

Correction Narrative: Administrator provided me with updated policy stating the records will be kept for two years. Policy is very detailed and compliance with minimal standard. Copies can be located in the shared drive.


facility_name: Hands of Faith GRO

summary: 748.3019(b) - Pest Control--Operation must use pest control operator licensed by TSPC Board or Dept. of Agriculture to prevent, control, eliminate pest infestations

raw_content: The operation is attempting to use chemicals on their own to control pests rather than using a licensed professional.

Correction Narrative: The administrator sent supporting documentation via-email of pest control receipt.


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

raw_content: While conducting a walk through of the operation there were ants found in the closet of one of the child.


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

raw_content: The date of a serious incident was not recorded.

Correction Narrative: The operation came into compliance by emailing the updated SIR with the date, the operation location and contact number, and how the incident was resolved.


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

raw_content: A serious incident did not provide the location and telephone number of the operation.


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: A serious incident documented that hospitalizing a child was how the incident was resolved.


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

raw_content: On Pg. 97 of the policies and procedures, the plan does not define what a conflict of interest would be as it relates to children who are placed at your operation or their families.

Correction Narrative: Policy was updated to meet the requirement of this rule.


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

raw_content: When reviewing the emergency evacuation/relocation diagram the diagram doesn't show a designated location in operation take shelter from threatening weather.

Corrected at Inspection: Yes


summary: 748.103(b)(11) - Policies and procedures to submit - Vaccine preventable diseases

raw_content: On pg. 230 the policies and procedure speak to verification of skin test. It does not identify which vaccinations are required if any.

Correction Narrative: The policies and procedures were updated to meet the rule requirement.


summary: 748.1219(1)(A)(i) - Treatment Services Admission-ED or ASD: Admission assessment must include psychiatric eval or psychological eval including child's diagnosis

raw_content: on page 99 of the policies and procedures the admissions criteria states that children can be placed if they have a outdated or a psychological completed within 6 months of placement. The rule for treatment services children is specific for ED. The policy is in conflict with standard number 748.1219 (1)(A)(i).

Correction Narrative: During the inspection the Administrator demonstrated an understanding of appropriate admissions criteria and the policies and procedures were updated to adhere to the rule.


facility_name: Rejo Helping Hands Inc.

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

raw_content: A staff member did not have training prior to being counted into ratio and conducting a restraint.

Correction Narrative: Four out of 4 staff members interviewed stated they have been recently trained on EBI. Training records were reviewed and verified to be compliant with minimum standards. The operation has come into compliance with this standard. Email received from operation 0n 12/23/2025: The LCCA and the Executive Director have ensured that all employees have EBI training and that all trainings are up to date. The LCCA and Executive Director has ensured that a refresher course on documentation training has been completed.


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

raw_content: Staff admitted to placing the child's arms behind his back.

Correction Narrative: Four out of four children interviewed denied seeing restraints involving staff twisting or placing a child's hands behind their back. Four staff interviewed denied the same. The operation has come into compliance with this standard. Email received from operation on 12/23/2025: The LCCA and Executive Director have ensured that all staff are trained in maintaining responsibility for the health, safety, and well-being of children always.  The administrator has reminded staff that they are to make sure that they are not to holding any manner other than the restraint holds that are taught.  The LCCA and Executive Director will continue to train all staff on all personal restraints, and to see if the staff can use another de-escalation technique before a personal restraint is used.  The LCCA has also ensured that training will be completed for all staff and that a refresher course on EBI training will been completed by 12/30/2025.


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

raw_content: During the inspection it was determined that the operation's fire inspection certification was expired.

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


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

raw_content: It was determined during this inspection that the operation's sanitation certification was expired.


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

raw_content: The operation created an incident with an incorrect child in care's name on it.

Correction Narrative: Email received from operation: The LCCA and Executive Director have ensured that all staff are trained in maintaining properly documenting incident reports. The administrator has reminded staff that they are to make sure that they are properly documenting to ensure we capture all incidents as they occurred. The LCCA and Executive Director will continue to train all staff on all personal incident report documentation. The LCCA has also ensured that training is completed for all staff and that a refresher training has been completed on documentation.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: A caregiver restrained a child in care with force, leaving a hand print. on the child's arm.


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

raw_content: Incident report was missing required information such as time, child's date of birth, date of admission...

Correction Narrative:
The LCCA and Executive Director have ensured that all staff are trained in documentation and that all reports are documented the correct way and filled out completely.

The LCCA and Executive Director will continue to train all staff in documentation. The admin team will check behind all staff to ensure that all reports are filled out completely.   Employees have had additional training, and all training courses are up to date.


summary: 748.2301(a) - Disciplinary Measures-only a caregiver known to and knowledgeable of the child may discipline the child

raw_content: A child visiting the operation threatened to discipline a child in care.

Correction Narrative:
The LCCA and the Executive Director have ensured that a child visiting the facility has never disciplined a child in care or tried to discipline a child in care. The LCCA did speak with all staff to let them know that this is not allowed at Rejo.

The LCCA and Executive Director has ensured that all staff have been made aware that no kid can discipline another child that is in care..


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

raw_content: Names of staff involved and witnesses not listed on serious incident report. Report mentioned staff intervened but staff was not listed.

Correction Narrative: The LCCA and Executive Director retrained all staff on how to correctly complete incident forms, including what information is required. Staff were instructed to review each form for accuracy and completeness before submission. Moving forward, Rejo Helping Hands will ensure all forms are filled out fully and submitted in a timely manner.


raw_content: Staff placed youth in cares arms behind their back and during a short personal restraint.

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

Correction Narrative: 3 out of 3 children interviewed denied witnessing any child restrained with their hands behind their back.3 out of 3 staff interviewed also denied restraints performed on children in care with their hands behind their back. The operation has come into compliance with this standard.


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

raw_content: Medication counts were inaccurate for all three boys' medicaition records.

Correction Narrative: LCCA double checked all the residents' records to ensure accuracy. Admin staff will check the records each day to ensure accurate counts.


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

raw_content: One of the three children's medication records reviewed was missing the times medications were administered.

Correction Narrative: LCCA double checked the medication records and made sure all records were accurate. The admin staff will review all records daily.


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: Three out of three medications were observed to be stored in disposable cups - outside of their original packaging.

Correction Narrative: The after-care specialist disposed of the disposable cups and properly disposed of all medication outside of its original packaging. The LCCA will ensure all medications remain in their original packaging until it's time to dispense medication to the residents.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: Three of the boys' medications are being prepared between 12 to 24 hours in advance.

Correction Narrative: The LCCA retrained staff on preparing medication, and medications will not be prepared more than 30 minutes in advance. Admin staff will check medication daily.


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

raw_content: Butter was not covered in the freezer, staff threw uncovered food.


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: Cleaning supplies and chemicals were on the table and under an unlocked cabinet in the rec room.  This was corrected by staff at inspection.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: The operation's fire extinguisher in the rec area was due to be serviced by the end of May 2025.


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

raw_content: Two of the three chest freezers did not contain thermometers

Correction Narrative: The executive director and LCCA ensures all freezers contain thermometers that are working properly.  LCCA will be doing weekly checks to ensure all thermometers are in the correct places.


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

raw_content: Unauthorized Absent Log is missing the age and gender of the victim.

Correction Narrative:
Email corrections submitted 7/25/25:
The LCCA and Executive Director has ensured that all forms are up to date and that all staff is trained on how to fill the updated forms out the corrected way. The LCCA and Executive Director will continue to check all forms and make sure that the forms are up to date. The staff of Rejo Helping Hands will ensure all forms are completed in a timely manner and filled out completely.


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

raw_content: The operation has been operating without an Administrator for more than 60 days.

Correction Narrative: Inspector received Form 2760 from the operation, showing that as of 06/02/25, Laverne Byrd has been hired on as the new LCCA. Ms. Byrd has been identified as a Controlling Person and verified to not being active at any other operations.


summary: 748.2551(d)(2) - EBI Implementation-Caregiver must make every effort to protect child's dignity and well-being, including ensuring that child's body is covered

raw_content: Staff removed a child's shirt from their body in front of other children in care while attempting to get the child to shower.

Correction Narrative:
Phone call to operation 7/25/25. Administrator stated that staff had in fact been retrained on proper de-escalation techniques and child rights. Email corrections submitted 7/4/25:
The LCCA and Case Manager has ensured that all staff has been retrained on appropriate EBI implementation and de-escalation techniques. LCCA and Case Manager will make sure that all trainings are up to date and that staff knows the rights of all residents that are in care at the operation.


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

raw_content: Staff used restraint in an effort to have child comply with taking a shower.

Correction Narrative:
Phone call to administration to follow up for deficiencies issued. Administration retrained staff on appropriate EBI implementation and de-escalation techniques.
Email corrections submitted 7/4/25:
LCCA and Case Manager has re-trained staff on appropriate EBI implementation and de-escalation techniques in an effort to avoid future incidents. LCCA and Case Manager will continue to monitor all staff on when EBI implementation is to be used and to ensure the safety of the residents and staff.


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

raw_content: The operation failed to ensure a caregiver had a completed background check prior to being hired.

Correction Narrative: Termination paperwork was received from the operation which shows termination for the staff member as of 6/11/2025.


summary: 748.303(a)(6)(B) - Serious Incident-Report to parents as soon as facility aware that child is indicted, charged, or arrested

raw_content: One of the two child case workers indicated they were not notified by the operation of the child arrest. The worker reported being notified by a Probation Officer on Monday on the incident that took place over the weekend. The worker denied missing a call over the weekend from the operation.

Correction Narrative: The operation will ensure all administrative personal are trained and knows the correct procedures, about notifying the caseworkers when a resident has been arrested.


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

raw_content: One of the two children Plan of Services was reviewed indicating the child is on 1:1 supervision. Two of the three staff indicated the child had 1:1 supervision; although they were not present when the child went on unauthorized absence. One of the three staff, that was present during the incident, indicated neither of the two children were on 1:1 supervision, which is contradictory to one child's plan of service.

Correction Narrative: The LCCA and case manager will ensure all staff are supervising residents according to their supervision plan to ensure they are safe. All staff will be monitored to make sure they are documenting all serious incident and calling the hotline.


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

raw_content: One of two child case workers indicated they had not been notified by the operation within six hours of determining their child was on unauthorized absence. The worker reported the unauthorized absence occurred on June 6, 2025, and the worker was notified by a Probation Officer on June 9, 2025, of the unauthorized absence.

Correction Narrative: LCCA and Case Manager have retrained staff on appropriate serious incident training. All staff have been trained on how long they have to call in a report to the hotline and on how to write and file a serios incident report


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

raw_content: The operation did not document the serious incident.

Correction Narrative: The Executive Director and LCCA will ensure that serious incidents will be called in a timely manner.


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

raw_content: According to documentation and interviews, the child injured their hand on 4/3/2025 but refused medical care until 4/4/2025. Staff made a report to SWI, however, the CVS parent did not receive the I&R until 3 days later on 4/7/2025. Thus, the CVS parent was not immediately notified of the critical injury immediately after ensuring the child's safety.

Correction Narrative: On 5/5/2025, the operation's CEO advised corrective actions taken include the Executive Director has ensured that all staff will notify the CVS parents in a timely manner, through email or text. The incident happened at school and was called in to the state hotline. To avoid this problem in the future, the Executive Director and staff will make sure that the CVS parent is a notified of every serious incident that happens with a child.


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

raw_content: One of four children's records reviewed did not have an initial service plan in the file.

Correction Narrative:
	All children records have been reviewed and missing service plans has been placed in the resident's binders
	The Executive Director and Case Manager will ensure that resident's binders are current, true, accurate and complete. Monthly checks will be done.


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

raw_content: Personnel records were not available for review when requested, records were locked up and staff did not have a key to access records.

Correction Narrative:
	A set of keys to the Case Manager's file cabinet has been copied and left onsite for the Admin staff to access personnel files.
	The Executive Director will ensure that records are available for review when requested.


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

raw_content: During a walk-through of the operation, cottage three had mold in the shower handel.

Correction Narrative:
	The shower handle has been replaced.
	All bathrooms have been for treated for mold.
	The Executive Director will ensure that the maintenance person check for mold during facility inspection


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

raw_content: Two of four children's records reviewed did not have an immunization record in the file.

Correction Narrative:
	Documentation for resident's refusal to get immunization has been placed in resident's binders.
 	The Executive Director and Case Manager will ensure that resident's binders are current, true, accurate and complete.


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

raw_content: During a walkthrough of the facility it was observed that there was one caregiver to 9 children in the recreational area.

Category: Child/Caregiver Ratios

Correction Narrative:
	There was 2 staff for 9 children. One of the staff walked out to monitor a child who left out of area. Staff will ensure that they either take a couple of kids with them to monitor a child who walks out of area or will call on the radio for back up Admin staff to assist with supervision of youth.
	The Executive Director will ensure that the child/caregiver ratio is maintained. The Admin staff is on call for additional supervision needs


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

raw_content: During the inspection, the children's records reviewed did not include a copy of the service plan invitation in the file. Additionally, two of the employee records reviewed lacked documentation of the drug tests taken.

Correction Narrative:
	All children records have been reviewed and missing service plan invitations has been placed in the resident's binders.
	All staff have been drug tested and documentation has been placed in their personnel file
	The Executive Director and Case Manager will ensure that resident's binders and employee personnel files are current, true, accurate and complete. Monthly checks will be done.


raw_content: One child initial service plan was not completed within 45 days after admission.

Standard Number / Description: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

Correction Narrative: This standard was found to be in compliance during a follow-up inspection.


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

raw_content: Employee was observed to be asleep during night shift.


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

raw_content: Staff failed to appropriately intervene during a serious incident involving a child in care exhibiting self-harm and making threats of harm to others, as well as engaging in self-injurious behavior.

Correction Narrative:
An in-person follow up was conducted on 04/12/25. Two children in care were interviewed regarding staff's response to serious incidents at the facility. Both children stated that staff immediately responded to them during serious incidents and provided appropriate support. There were no outcries of abuse or neglect.
The following corrective action was emailed on 04/29/25: 	The Executive Director and staff will ensure that they remain up to date on EBI training.  Staff did intervene and the resident was placed in a child restraint. Once staff released the child, child started to hit his self again.


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

raw_content: The administrator failed to communicate with all caregivers a children's risk behaviors.


summary: 748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard

raw_content: The top bunk bed was observed to have no safety bedrails.


summary: 748.125(f)(2)(B) - Post hospitalization protocols must include creating or reviewing and updating the childs safety plan.

raw_content: There wasn't a post hospitalization safety plan created/updated after a child's hospitalization stay.

Correction Narrative:
An email/corrective action was received on 04/04/2025 stating the following:
PLSP and the administrator assured that a copy of the resident's post hospitalization safety plan is filed in the resident's binder. The resident's safety plan was updated. The residents will continue to have 1:1 supervision. A search of all areas (bathroom, bedroom, common area and all dresser drawers) will be conducted every 10-15 minutes.
 The Administrator will ensure that all office staff are placing a copy of all safety plans in the residents' binder. As well as updating an existing safety plan as necessary.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content: The required PLSP debriefing wasn't conducted with a child post hospitalization.

Correction Narrative:
An email/corrective action was received from the operation on 04/04/2025 stating the following: Making sure that all post hospitalization safety plans are filed in the resident's binder. Also, we are implementing a system for following up with the residents at least twice a week to make sure that we are providing ongoing support, and the resident is safe at all times.
 The Administrator has ensured that all safety plans are up to date and filed in the residents' binder. And a weekly check of the binders will be enforced to make sure that all existing safety plans are up to date.


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

raw_content: A staff member involved other children when attempting to de-escalate a situation with one child in care.

Correction Narrative: This standard was found to be in compliance during follow-up inspection.


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

raw_content: A child in care reported being attacked by other children in care by the direction of a staff member. The victim sustained injuries that required medical attention.


raw_content: Three of the four records reviewed was observed to have immunization records in the admission documentation.

Standard Number / Description: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

Correction Narrative:
Resident's Immunization record was placed back in his binder. It was taken out to give the school a copy.
The Administrator and Case Manager will ensure to place all resident's documents back in their binders.


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

raw_content: One of four staff members was observed to have an expired CPR Certification.

Correction Narrative: All caregivers CPR trainings are now up to date.		The Administrator, Executive Director, and Case Manager will ensure all trainings will be completed in a timely manner.


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

raw_content: Two of four Admission Assessments reviewed was observed to not be signed or dated from the Professional Level Service Provider.

Correction Narrative:
PLSP has signed the assessment.
The PLSP will sign the assessment immediately after the paperwork has been completed, to avoid forgetting.


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

raw_content: One of four Child Right's documents reviewed for a child admitted on 07/29/2024 was observed to be missing the child's signature.

Correction Narrative:
Resident has signed the Child's Right.
The Case Manager will ensure that after reading the Child's Right to each child, that child understands the Child's Right and will have child sign.


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

raw_content: Case manager reported that some staff files could not be reviewed due to them being forgotten at her personal residence.

Correction Narrative:
All active records are at the facility.
Staff will not remove records from the facility, even if internet isn't working.


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

raw_content: One of four Preliminary Service Plans reviewed was observed to be missing a signature from Treatment Director or Professional Level Service Provider.

Correction Narrative:
Treatment Director and PLSP has signed and dated service plan
The PLSP and Treatment Director will sign the service plan immediately after the paperwork has been created.


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

raw_content: Neither of the four staff files reviewed was observed to be current in Suicide Training.

Correction Narrative: Caregivers have completed the suicide training.	The Administrator and Case Manager will diligently housekeep personnel files to ensure all employees are completing trainings to remain in compliance.


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

raw_content: One of the four staff files reviewed was observed to be delinquent in annual Emergency Behavior Intervention Training.

Correction Narrative: All caregivers are now up to date on EBI training. They have met the requirement of 8 hours of EBI every 6 months. 		The Administrator, Executive Director, and Case Manager will ensure all trainings will be completed in a timely manner.


summary: 748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.

raw_content: Two of the four staff members records involved was observed to be delinquent on Normalcy Training.

Correction Narrative:
All Caregivers had the one hour required normalcy training.
Staff will ensure that all certificates be placed in personnel files.


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 annual fire inspection was not completed timely.

Correction Narrative:
The operation stated:
	The Executive Director has placed all inspection due dates on the Calendar which will alert us a month in advance to complete inspections.
	The Executive Director, Case Manager, and LCCA will ensure that all inspections going forward will be completed. If we weren't moving locations this week, we would have scheduled an inspection as soon as possible to prevent being out of compliance.


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

raw_content: The annual summary log does not have how long the child was gone for. The log has a designated area for time and date of return however only the date is being entered.

Correction Narrative:
The operation stated:
	The summary logs have been updated to include the time the child returned. Notwithstanding, the return date and time was documented on the Serious Incident Report.
	The Administrator will ensure that staff is documenting the return date and time on the SIR's, as well as the summary logs.


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

raw_content: An incident report was observed with additional information that was not reported to SWI.

Correction Narrative:
	Staff have been briefed to provide a complete, honest account of what happened that led them to call SWI.
	The Director and Administrator will provide ongoing refresher documentation trainings to all staff.


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: 1 of 3 records was observed without a TB exam. Staff was hired 6/9/23.

Correction Narrative: The Administrator and Case Manager will audit files regularly to prevent files being misplaced or duplicated.


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: One medication, Guanfacine 2MG, was supposed to be administered daily at 4pm, was administered after 4pm on 7/5-7/13.

Correction Narrative:
The operation stated
The Director and Administrator will ensure that all residents medication is being properly administered at prescribed times by using check and balance system.
If staff is out with residents, staff will ensure to bring medication for residents to administer medication at prescribed time.
Medication logs received showed the child was given the medication timely unless he was off campus, in which instance it was given upon his return. Logs were uploaded into digital storage.


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

raw_content: 1 of 1 service plan reviews were missing all signatures.

Correction Narrative:
The signed service plan was overlooked in the child's binder.
Staff will ensure that the correct copy of the signed service plan is under the correct tab in the children's binder.


summary: 748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history

raw_content: 4 of 4 admissions assessments did not include the child's birth and neonatal history; (c)(6) childs school history, including the names and dates of previous schools attended, grades earned, and special achievements; (c)(7) the reason for the previous placements.

Correction Narrative:
Staff has updated the admission assessment to include the required information of neonatal history and previous schools attended.
PLSP will audit the children binder's to ensure compliance with Minimum Standards in being met.


summary: 748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs

raw_content: The evaluation of the child's progress was not thoroughly documented on 2 of 4 service plan reviews.

Correction Narrative:
Staff has updated the service plan with more detail on the progress of the child.
All service plans will be more detailed going forward


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

raw_content: 4 of 4 records reviewed did not include the results of the child's suicide risk screening.

Correction Narrative:
All records had the results of the child's suicide risk screening in the binder.
PLSP made a tab specifically for suicide screenings to avoid being overlooked.


raw_content: Service plans reviewed noted the effective date of the plans to be before the completion dates of the plan; the supervision and ratio requirements are inconsistent between the preliminary, initial, and review service plans; admission's assessments, preliminary, initial, and review service plans were not individualized and detailed for each child in care; dates did not accompany all signatures on documents, for example initial and review service plans, to show when the document was signed and to ensure compliance with minimum standards timeframes; information from the application for placement, psychological assessment, and admission's assessment were not thoroughly included in the goals and needs documented for children in care in their initial and review service plans

Correction Narrative:
The service plans were updated to reflect the correct effective and completion date of the plans.
Staff will ensure that the dates are consistent between the effective date and completion date.
Staff will ensure that the supervision and ratio requirements are consistent between the preliminary, initial, and review service plans.
Staff will double checked to make sure there is not typo's in service plans.


summary: 748.1347(a)(2) - Initial Service Plan-Document PLSP's date of participation

raw_content: 3 of 4 initial and review service plans did not include the date of participation for the PLSP. 1 service plan did not include the signature of the PLSP.

Correction Narrative:
All service plans have been signed and dated.
All service plans will be signed and dated at time of participation prior to filing


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

raw_content: 3 of 4 placement agreements did not include the reason for placement and the anticipated length of time in care.

Correction Narrative:
PLSP will double check paperwork prior to intake to ensure the Placement Authorization is completed correctly.
PLSP will make contact with Intake at SSCC's to ensure that they are filling out paperwork correctly. The placement agreement comes from the SSCC.


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: During interview, staff admitted to threatening a child with corporal punishment.

Correction Narrative: 3 residents were interviewed during the follow up inspection and they did not express any concern. 2 staff was interviewed and they confirmed that training was held with all staff on 7-21-23 and during the training staff were reminded to ensure they dont use any form of corporal punishment as well as no use of any threatning words against any child. Residents did not make any disclosure of corporal punishment being used on them during interview. No disclosure was made.


raw_content: The annual fire inspection was due on 4/1/23.

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

Correction Narrative:
	Facility has been inspected by Fire Marshall. It currently expires 4/18/2024.
	All inspections have been placed on the Calendar to keep up with upcoming inspection deadlines to prevent exceeding expiration dates.


raw_content: One preliminary service plan was missing the signature from the PLSP/Treatment Director.

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

Correction Narrative:
The operation stated:
Treatment Director signed and dated the Preliminary Service Plans.
All forms will be signed and dated by correct staff member going forward before filing, scanned, or emailing.


raw_content: One medication record reviewed showed a child received Lovastatin on 10 days, in the morning, when the instructions stated it should have been given with an evening meal. The same record showed the child was given Omega 3 Acid once a day on 1/12/23 and 1/17/23 when it was prescribed to be given twice a day. The child also received Aripiprazole only once on 1/17/23, when it was prescribed to be given twice daily.

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

Correction Narrative:
The operation stated:
All Medication Logs have been reviewed for quality assurance.
The specific MAR for Lovastatin, Omega 3 Acid, and Aripiprazole has been pulled and reviewed with ALL staff to show and educate staff to follow exact prescription written on the actual medication and record when medicine is given.
Medication has been counted three times by Administration to ensure accuracy and to ensure residents have taken the medication as prescribed.
The Executive Director and Administrator will conduct checks throughout the day to ensure the medication has been given and that the counts are accurate with all prescribed and needed information.
On January 19, 2023, staff was re-trained on administering medicine and medication monitoring.


summary: 748.1217(b)(12) - Admission Assessment-At admission, must include services the operation plans to provide to the child

raw_content: 4 of 4 admissions' assessments did not include the services the operation would provide to children in care, and the child's substance abuse history, and the child's understanding of placement.

Correction Narrative:
The operation stated:
The Admission Assessment form has been updated to include the services Rejo Helping Hands will provide to each child, the child's understanding of placement and the child's substance abuse history.
	Verify and reference the Minimum Standards to remain in compliance.
Use the updated Admission Assessment form going forward.


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

raw_content: One file did not include the child's immunization record.

Correction Narrative:
The operation stated
The Treatment Director and Administrator will ensure that all residents' files are being maintained with all correct and appropriate paperwork being in the resident's binders.


summary: 748.1331(b)(5) - Preliminary Service Plan-For child receiving treatment services, designate who will be responsible for meeting each of the child's needs

raw_content: 4 preliminary service plans did not document who would be responsible for meeting each of the child's needs.

Correction Narrative:
The operation stated:
All children's Preliminary Service plans has been updated to include which staff will be responsible for meeting each of the child's needs.
Verify and reference the Minimum Standards to remain in compliance.
Use the updated Preliminary Service Plan form going forward.


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

raw_content: 4 of 4 records reviewed had medication logs with the reason for the medications not listed.

Correction Narrative:
The operation stated:
Executive Director corrected all forms that were missing reason for prescription and input the missing reason for prescription medication.
The Executive Director and Administrator will conduct checks to ensure the MAR's are accurate with all prescribed and needed information.


summary: 748.864(d) - Pre-Service Training-Document the completion of each training requirement in the appropriate personnel record.

raw_content: The administrator personnel file did not contain any of the trainings documents.

Correction Narrative: Operation created a form for keeping track of all training records for all employees. A form was provided for licensing.


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

raw_content: Of the two files reviewed, neither employee had a signed statement of reporting abuse or neglect.

Correction Narrative: Operation created and provided a form that all employees will review and sign regarding reporting abuse and neglect. A copy of this form was provided to licensing.


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

raw_content: During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Correction Narrative: Operation provided at home drug testing kit, which will be administered by a certified collector. The at home drug test, has been verified by the FDA and is 99% accurate. It tests for a multitude of drugs.


summary: 748.105(3)(B) - Personnel policies-develop professional staffing plan that describes qualifications/duties/responsibilities/authority of professional positions

raw_content: The personnel policies do not include all required information for the professional positions. The personnel policies were missing a professional staffing plan with required information.

Correction Narrative: Operation provided the Personnel policy to residential child care licensing.


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

raw_content: During the application review, the staff did not have valid First Aid and CPR Training in their file.

Correction Narrative: Staff completed the first aid CPR training.


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

raw_content: During the walk through there were several physical site issues such as a hole in the ceiling on the corner of bedroom 4, a broken drape handle, a hole in the wall with chipped paint in bedroom 3. Additionally, the air ducts needed to cleaned. Work orders were provided.


summary: 748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued

raw_content: The sanitation inspection was not present and needs to be sent in writing.

Correction Narrative: Operation obtained a letter from the City of Houston where it documents that an inspection by the Houston Department of Health and Human Services is not required.


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

raw_content: During the application review, C.R. as the PLSP job description is missing the 2 years of experience, education requirement and training does not meet the minimum standards for this position.

Category: Personnel

Correction Narrative: Operation provided a copy of the college transcript for staff member in question.


summary: 748.103(b)(12) - Policies and procedures to submit - Weapons, firearms, explosive materials and projectiles

raw_content: The weapons, firearms, explosive materials and projectiles policy is missing from the operational policies.

Correction Narrative: Operation provided the weapons policy to residential child care licensing.


summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content: During the inspection, the abuse and neglect policies are missing from the operational policies.

Correction Narrative: Operation provided the abuse and neglect policy to residential child care licensing.


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

Deficiency Narrative: During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.


summary: 748.113 - EBI policy - develop EBI policies if my operation is permitted to use EBI

raw_content: The EBI policy is missing information, such as what restraints are acceptable.

Correction Narrative: Operation provided the emergency behavior intervention policy to residential child care licensing.


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: During the inspection, the staff did not have a record of a TB in their file.

Correction Narrative: Staff member had tb test completed on 7/24/22.


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

raw_content: During the application review, staff files did not have an adequate amount of required training and the file was missing training hours.

Correction Narrative: Staff completed all required orientation training and pre-service training.


summary: 748.111 - Child-care policy required

raw_content: The child care policy is missing information including education, child's rights and religion.

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

Correction Narrative: Operation provided the child care policy to residential child care licensing.


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 and e-cigarette policy is missing from operational policies. This policy should be address both staff and children in care.

Correction Narrative: Operation provided the tobacco policy to residential child care licensing.


facility_name: A Promising Journey Inc.

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

raw_content: During walk through, it was observed in the downstairs bathroom shower, mold in adjacent corners of the door frame, each ranging in about 3 in wide in diameter.


summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: The service plan report reviewed for this investigation had several areas left blank to include summary of goals, needs and strengths sections, summary progress for goals, medication list, triggers, target dates, emotional disorders, and missing signatures.

Correction Narrative:
An email was sent with the following correctives:
Per your request, corrections for Investigation

On Friday, August 02, 2024, A Promising Journey received a letter pertaining to per said investigation stating standard:

748.1337 (b) Initial Service Plan-Document in the child's record to include preliminary service plan requirements

It was determined that the Service Plan was missing several blank areas including the summary of goals, needs and strengths sections, summary of progress goals, medication list, triggers, target dates, emotional disorders, as well as missing signatures.

A Promising Journey (APJ) sets policies and procedures for residents/staff to increase accountability, professionalism, progress, and avoid unnecessary crisis and/or violations.

Service Plan documentation is also a part of policies and procedures as a method of ensuring that APJ monitors and records all of residents' progress and performances.

Moving Forward

The Professional Level Service Provider/Case Manager/Licensed Child Care Administrator will ensure that each child's service plan is completely individualized and detailed to ensure that the child's needs are evaluated and met in all areas of service and need, including but not limited to signatures.

Failing to do so may result in staff being removed from their work schedule pending results from investigation and/or allowed to work in another area.


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

raw_content: Several medication records were observed missing the reason the medication was prescribed. The case manager went through the medication log and entered the reason medication was prescribed for each child prior to the inspection concluding.


summary: 748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication

raw_content: A child in care received another child's prescribed medication.

Correction Narrative: Three children's interviews were conducted, and they each described the medication administration procedure requiring preparation apart from the household members, no talking during medication administration, and two step verification process.


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: A serious incident was not reported to Licensing when an officer responded to an incident at the operation.

Correction Narrative:
On 02/16/24 an email was sent with the following correctives: During orientation to the facility, as well as annually, staff will be taught the importance of notifying the LCCA immediately, calling the Hotline (within 24 hours), as well as strategies and techniques to provide the best care, welfare, safety, and security for all.
Staff will document all altercations (physical and/or verbal), teaching residents to report to an adult (be a direct care staff, Case-manager, LCCA, etc.), while maintaining a safe and secure environment.

Failing to do so may result in staff being removed from the work schedule pending results from investigation and/or allowed to work in another area under a safety plan.


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: It was determined that the incident report is missing the resolution of the incident. It also does not include any child or adult witnesses.

Correction Narrative:
An Email was sent with the following correctives which stated: It was determined that the incident report is missing the resolution of the incident and did not include any child or adult witnesses.

A Promising Journey (APJ) sets policies and procedures for residents/staff to prevent injury, increase accountability, and avoid unnecessary crisis.

Documentation is also a part of policies and procedures as a method of ensuring that APJ monitors and records all incidents of residents, staff, and that we are using best practices.
After an incident is managed (staff being in arms reach as well as in close sight), a critical report will be completed for the resident and stored in her file. Documentation of the event will be kept in the resident's file. Information within the report will include:
1.	Type of incident
2.	Date and time of the incident
3.	Supervisor contacted, including method of contact, and time of contact.
4.	Local authorities contacted and the time of contact (if applicable).
5.	Case worker contacted, time and method of contact.
6.	Hotline called, time of call and incident number given (if applicable).
7.	Documentation of the incident location, when completed.
8.	End result/resolution; and
9.	Witnesses (child and/or adult)


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

raw_content: It was determined that one caregiver was not able to intervene during a fight due to an injury to the ankle.

Correction Narrative:
An email was sent that stated the following corrections. Staff who have any personal circumstances that may limit their performance while scheduled (physical or otherwise) must consult their manager prior to their attendance.
When/Where necessary, staff who may be limited in their ability to perform all duties as assigned, must seek advice from their health care provider before reporting to work. Staff (injured or experienced an accident) must/will use prudent judgement when stationed in an area that requires physical involvement by tagging out with a peer and reporting the change to their immediate supervisor.
During orientation to the facility, as well as annually, staff will be taught strategies and techniques they can use to provide the best care, welfare, safety, and security for all.
Staff will document all altercations (physical and/or verbal), as well as teach residents to report  to an adult (be a direct care staff, Case-manager, LCCA, etc.), while maintaining a safe and secure environment. Failing to do so may result in staff being removed from work schedule pending results from investigation and/or allowed to work in another arean under a safety plan.

Follow-up interviews were also conducted with children in care.


summary: 748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations

raw_content: No contact with a health care professional was made when the child was given the wrong medication.

Correction Narrative:
An email was sent with the following correctives: When a medication administration error occurs, staff will follow these guidelines:
1.	keep the resident in the room where medication was dispensed.
2.	If the resident has already returned to her room, have someone accompany the resident back to the area where dispensed.
3.	observe the resident's status and document what you see.
4.	identify the incorrect dose or type of medication taken by the resident.
5.	notify the case manager and supervising staff immediately if medication was given by non-licensed personnel (The supervising staff will contact the LCCA, Executive Director, and/or health care provider of the resident.)
6.	if contacting the Poison Control Center for instructions:
a.	give the name and dose of the medication taken in error.
b.	give the resident's age and approximate weight, if possible
c.	give the name and dose of any other medication the resident receives, if possible
7.	follow instructions from the Poison Control Center, if possible.  If unable to follow their instructions, explain the problem to the Poison Control Center to determine if the resident should be transported for emergency care.
8.	Notify the resident's health-care provider via telephone, document, follow up with an email, and adhere to the given instructions/recommendations.
9.	complete the Critical Incident Report form. Carefully record all circumstances and actions taken, including instructions from the Poison Control Center and/or the residents' health care provider, and the resident's status.  All reports are to be filed and kept according to A Promising Journey Inc.'s policy.

Lastly, errors made in recording medications on the Medication Administration Record should be marked void/error initialed and dated. Whiteout may not be used.  Medical errors may lead to fines, corrective action and/or a finding of abuse.


summary: 748.455(a)(2) - Unauthorized AbsenceDebrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies

raw_content: The form is missing a spot for trauma informed strategies child can use, a spot for child conditions, what occurred while gone and any inappropriate activities for the child to return to.


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

raw_content: The form is missing a determination of how the operation can meet their needs and if they are emergency placement.


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: missing from policy

Category: Emergency Behavior Intervention

Deficiency Narrative: missing from policy


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

raw_content: Missing from policy

Deficiency Narrative: Missing from policy


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

raw_content: The form is missing who the child can leave with.


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

raw_content: There was not a job description for volunteers.


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

raw_content: No transitional living policy

Deficiency Narrative: No transitional living policy


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: There is no place for cold medication.

Deficiency Narrative: There is no place for cold medication.


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: Three out of three employee files reviewed did not contain a record of TB skin test results.


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

raw_content: The form is missing gender and date of admission.


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

raw_content: No policy for private placement for fees


facility_name: Ray's of Life

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

raw_content:
Upon review of staff files, it was seen that 1 of 1 file did not have a start date to reference.

Operation had no employment history verified.

Operation had no job description for the staff in the file.

Operation did not have a signed statement that confirms employee read operational polices.

No signed statement confirming that the employee will immediately report suspected abuse, neglect, or exploitation per policy.

Correction Narrative:
Upon receiving the citation, Rays of Life conducted a full audit of the cited staff file and immediately completed the following corrective actions:
1. Employment Documentation Completion
	The employees official start date was added to the personnel record.
	Previous employment history was obtained, verified, and documented, including contact information and dates of employment.
	A formal job description outlining duties, expectations, and position responsibilities was issued, reviewed, and signed by the employee.
2. Policy & Reporting Acknowledgements
	The employee signed the Operational Policies Acknowledgment, confirming they reviewed and understood the operations policies, procedures, and standards.
	The employee signed the Mandatory Abuse/Neglect Reporting Statement, confirming their legal obligation to report suspected abuse, neglect, or exploitation in compliance with DFPS requirements.
	These documents were filed in the personnel record in their designated sections.
3. Background Check Documentation
	A printed verification of the employees completed background check was obtained and placed in the confidential section of the personnel file under restricted access.
	A new confidential records divider and labeling system was implemented to ensure compliance with confidentiality standards.
________________________________________
C. Preventative Measures Implemented
1. Employee Personnel File Checklist Implementation
A comprehensive Employee Checklist is now required for every new employee and must be initiated immediately when a potential employee is identified.
The checklist includes:
	Background check verification
	Job description acknowledgment
	Operational policies acknowledgment
	Mandatory reporting statement
	Training verifications
	Employment history
	Start date documentation
	Driver/transport clearance (if applicable)
The checklist must be signed by leadership upon completion.
2. Enhanced Onboarding Procedure
A standardized onboarding workflow has been created to ensure all personnel documents are completed before an employee works with children.
3. Quarterly Personnel File Audits
Leadership will conduct a quarterly audit of all staff files using a formal audit form.
Any inconsistencies will be corrected immediately.
4. Secure and Standardized Recordkeeping System
Personnel files are now maintained in a centralized, locked filing system with standardized labeling and dividers for:
	Required documents
	Confidential documentation
	Training records
	Compliance forms
This ensures DFPS records are organized, complete, and accessible for inspection.
D. Compliance Verification
Verification will be demonstrated through and completed by the LCCA.
	Completed Employee Checklists
	Quarterly personnel audit documentation
	Updated and organized personnel files
	Confidential section verification logs


summary: 748.365 - Personnel records-Background check results must be kept confidential and protected from unauthorized access or release

raw_content: Upon inspection of 1 of 1 staff file's it was viewed that no physical copy background check was input into personnel record.


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

raw_content: The operation doesn't have an unauthorized absence debriefing form.

Correction Narrative: An email containing an attachment of the modified unauthorized absence debriefing received from the executive director.


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

raw_content: The unauthorized absence annual summary log presented during the inspection did not include the age, gender, or date of admission.

Correction Narrative: An email containing an attachment of the modified unauthorized absence log received from the executive director.


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

raw_content: The evacuation diagram was observed without a shelter in place indicating the designated location.

Correction Narrative: An email containing an attachment of the modified evacuation & relocation diagram received from the executive director.


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

raw_content: Upon review of June, July, & August recreational calendars there was no indication of scheduled indoor/outdoor activities.

Correction Narrative: An email containing an attachment of the month of November recreational calendar received from the executive director.


summary: 748.3307(b)(2) - Physical Site-Common use rooms, such as dining rooms, living rooms, laundry rooms, and gymnasiums must be lighted to avoid accidents

raw_content:
During the inspection is was discovered that the light fixture in the common area children have access to is not in working condition. The light switch was flipped up and the light fixture did not turn on.

There were steps with large wood chips pieces missing.

The fence in the backyard was in need of repair. The wooden panel & slate need to be nailed into the fence post.

The staircase railing on the left side was observed being loose as children walked up and down the stairs.

Correction Narrative:
2. Immediate Corrective Action Taken
	The common area light fixture was repaired/replaced immediately to restore proper lighting.
	The outdoor steps were repaired and reinforced to eliminate hazards.
	The backyard fence panels and slats were secured with new nails and stabilizers.
	The left staircase railing was tightened and reinforced to ensure child safety.
	Leadership completed a full walk-through of the home to ensure no additional hazards were present.
(If you want, I can tailor this to match the actual dates repairs were completed.)
3. Long-Term Preventative Measures
To ensure physical site compliance on an ongoing basis:
A. Third-Party Maintenance Contract Implemented
Rays of Life has secured a third-party maintenance professional who will:
	Conduct quarterly preventative inspections of the entire property.
	Respond as needed for any repairs identified by staff or during inspections.
	Provide written documentation of all work completed.
B. Monthly Internal Leadership Site Inspections
Leadership will conduct and document monthly maintenance walk-throughs, specifically checking:
	Lighting in common use rooms
	Stair rails and handrails
	Outdoor structures (steps, fence, entry/exit points)
	Indoor safety-related structural items
C. Maintenance Request & Tracking Log Updated
A maintenance log has been implemented to track:
	Date concern identified
	Person who identified the concern
	Description of the physical issue
	Date repair was completed
	Verification signature from leadership

5. Responsible Parties
	Executive Director
Oversees maintenance strategy, vendor coordination, and CAP compliance.
	Administrator
Conducts internal monthly inspections and reviews maintenance logs.
	Third-Party Maintenance Professional
Performs quarterly inspections and repairs as assigned.


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

raw_content: Six children in care were observed with only one staff member present.

Correction Narrative:
On September 16, 2025 an email was received from the Administrator stating; Ray's of Life management
team acknowledges the importance of maintaining
required child/caregiver ratios to ensure the safety, supervision, and developmental needs of
children in care. To address this concern, we have
implemented a revised staffing plan and identified
trained PRN caregivers to provide coverage in the event of staff shortages, illness, or emergencies. In addition, daily attendance, staffing schedules, and staffing records will be monitored by the
Executive Director and or Administrator to confirm
ongoing compliance with ratio requirements, and all
caregivers will receive refresher training on CCR
standards. These steps will help ensure that ratios are consistently maintained and that the safety and well-being of all children remain our top priority.


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

raw_content: When RCCR Inspector arrived at the operation for inspection, a caregiver was outside seated in a car while multiple children in care were awake and walking about in the living room of the home. The caregiver was the only one on duty at the time.

Correction Narrative: Inspector talked to 3 of the 7 kids who confirmed there is typically 2 to 3 staff present during the day and a least 1 staff at night. During the walk-through ratio was confirmed compliant.


summary: 745.651(2)(A) - Background Check Validation - Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content: During the inspection it was determined that the last validation date of the employee background checks was completed on 02/24/2025.

Correction Narrative: Ray's of Life GRO Administrator/Executive Director/Manager will address the deficiency regarding failure to validate background checks every three months. The operation has completed a full review and validation of the current list of all staff, volunteers, and individuals requiring background checks as of 06/13/2025.  Moving forward, a recurring calendar reminder and a compliance tracking system have been established to ensure that background check validations are conducted and documented every three months, as required. The Administrator/Executive Director/Manager or designated compliance coordinator will be responsible for completing and maintaining accurate records of each quarterly validation.


summary: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks

raw_content: During the inspection, it was determined that the gas inspection certificate of the operation was expired.

Correction Narrative:
Ray's of Life GRO Administrator/Executive Director/Manager will address the deficiency regarding the timely inspection of the facility's gas system. The operation has scheduled a licensed gas inspection to be completed by 06/13/2025, in order to meet the required 24-month inspection interval. A copy of the inspection report will be maintained on-site and submitted to the appropriate licensing authority once the inspection is completed. To prevent recurrence, a tracking system including calendar reminders and a compliance log has been established to ensure that future gas inspections are scheduled and completed within the required timeframe. The Director or Facilities Manager will review all facility safety inspection deadlines on a quarterly basis to maintain ongoing compliance with regulatory maintenance schedules.

Gas leak test was completed on 6/12/25.


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

raw_content: It was observed that a child did not receive the morning dosage of his prescribed medication on 03/19/2025.

Correction Narrative: During the inspection, an audit of the medications of four out of seven children in care showed that medications are now being administered and documented timely.


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

raw_content: A child's evening medication log was observed to be documented early in the day on 03/19/25 showing that the medication was administered, although it was not.

Correction Narrative: Ray's of Life GRO Administrator/Manager/Supervisor/ will ensure that the medication record will be reviewed and all staff will receive immediate training on documentation requirements as outlined in the minimum standards. The training will specifically address the importance of timely and accurate recordkeeping, emphasizing that the cumulative medication record must be updated within two hours of administration. To support compliance, a new documentation protocol will be implemented, including real-time entry expectations and supervisor verification during shift changes. Oversight will be provided by the program director or designee, who will review medication logs daily to ensure timely entries are made. Staff who fail to meet documentation requirements will receive corrective feedback and, if necessary, additional retraining.