summary: Licensing visited the facility to review video from the early morning hours of 9/10/23 – 9/12/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
United Methodist Children's Home Little Rock Campus Clayton DeBoer
2002 SOUTH FILLMORE Donaghey Plaza
LITTLE ROCK AR 72204 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 115
Date of Visit: 9/13/2023
Visit Type(s): Monitor Visit
Time: 10:00 AM - 10:22 AM
_______________________________________________________________________________________________
Visit Comment :
Visit conducted and video reviewed from the early morning hours of 9/10/23, 9/11/23 and 9/12/23.
9/10/23:
Hall A night visual checks conducted at 3:00AM, 3:15AM and 3:20AM
Hall B night visual checks conducted at 2:59AM, 3:14AM and 3:30AM
Hall C night visual checks conducted at 2:59AM, 3:14AM and 3:30AM
Hall D night visual checks conducted at 2:59AM, 3:14AM and 3:31AM
9/11/23:
Hall A night visual checks conducted at 2:59AM, 3:15AM and 3:28AM
Hall B night visual checks conducted at 3:13AM, 3:28AM and 3:44AM
Hall C night visual checks conducted at 2:59AM, 3:14AM and 3:29AM
Hall D night visual checks conducted at 2:59AM, 3:14AM and 3:30AM
9/12/23:
Hall A night visual checks conducted at 3:00AM, 3:14AM and 3:30AM
Page 1 of 2

Hall B night visual checks conducted at 2:59AM, 3:14AM and 3:29AM
Hall C night visual checks conducted at 2:59AM, 3:15AM and 3:29AM
Hall D night visual checks conducted at 3:00AM, 3:15AM and 3:29AM
All checks conducted within 30 minutes.
CCL Staff Signature : Date: 9/13/2023
Provider Signature : Date: 9/13/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


state: AR

facility_name: United Methodist Children's Home - Little Rock

summary: An x-ray was ordered after a resident injured his hand by punching a door.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/12/2023
Date Received by DCCECE:9/13/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , dob , he is in parent custody. was in
the dayroom, upset about having to leave the gym. walked out of the dayroom,
walked into the hallway and punched the door. He was assessed by the nurse due to
swelling and bruising of his right hand. The on-call medical doctor ordered an x-ray. The x-
ray was completed on 9/13/23 at 8:39 a.m. There were no findings of a fracture.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received report 9/13/23 that on 9/12/23 client
was in the dayroom, upset about having to leave the gym. walked out of the
dayroom, walked into the hallway and punched the door. He was assessed by the nurse due
to swelling and bruising of his right hand. The on-call medical doctor ordered an x-ray. The
x-ray was completed on 9/13/23 at 8:39 a.m. There were no findings of a fracture. No
licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: An x-ray was ordered after a resident fell and injured her foot while playing a game in Recreational Therapy.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/12/2023
Date Received by DCCECE:9/13/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , dob , she is in parent custody. was
playing a game in Recreational Therapy when she fell and hurt her left foot. She was
assessed by the nurse for pain in the left ankle and joints of the left foot. The doctor order an
in-house x-ray. The x-ray findings were normal, there were no indications of a fracture.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received report 9/13/23 that on 9/12/23 client
was playing a game in Recreational Therapy when she fell and hurt her left foot.
She was assessed by the nurse for pain in the left ankle and joints of the left foot. The doctor
order an in-house x-ray. The x-ray findings were normal, there were no indications of a
fracture. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review video of the early morning hours of 9/3/23 and 9/4/23. The facility was cited 907.6 for issues identified during the review.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
United Methodist Children's Home Little Rock Campus Clayton DeBoer
2002 SOUTH FILLMORE Donaghey Plaza
LITTLE ROCK AR 72204 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 115
Date of Visit: 9/6/2023
Visit Type(s): Monitor Visit
Time: 9:00 AM - 9:34 AM
__________________________________________________________________________
Regulation# 9 . 907 . 6
Result : Non-Compliant
Action Due Date : _______________Date Corrected:
Action Due :
Comment : 46 minutes in between night visual checks in video viewed.
_______________________________________________________________________________________________
Visit Comment :
Facility visited 9/6/23 and video reviewed of the early morning hours of 9/3/23 and 9/4/23.
9/3/23:
Hall A night visual checks conducted at 1:16AM, 1:44AM and 2:15AM
Hall B night visual checks conducted at 1:15AM, 1:44AM and 2:09AM and 2:55AM, 46 minutes in between
checks. Facility cited 907.6.
Hall C night visual checks conducted at 1:00AM, 1:15AM and 1:30AM
Hall D night visual checks conducted at 1:00AM, 1:15AM and 1:30AM
9/4/23:
Page 1 of 2

Hall A night visual checks conducted at 1:04AM, 1:24AM and 1:41AM
Hall B night visual checks conducted at 1:04AM, 1:23AM and 1:40AM
Hall C night visual checks conducted at 1::00AM, 1:15AM and 1:29AM
Hall D night visual checks conducted at 1:00AM, 1:15AM and 1:29AM
CCL Staff Signature : Date: 9/6/2023
Provider Signature : Date: 9/6/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2

doc_type: Compliance Report


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough and to review video of the early morning hours of 8/20/23 – 8/21/23. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
United Methodist Children's Home Little Rock Campus Clayton DeBoer
2002 SOUTH FILLMORE Donaghey Plaza
LITTLE ROCK AR 72204 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 115
Date of Visit: 8/23/2023
Visit Type(s): Monitor Visit
Time: 11:30 AM - 0:20 AM
_______________________________________________________________________________________________
Visit Comment :
Video review conducted for the early morning hours of 8/20/21 and 8/21/23:
8/20/23:
Hall A visual checks conducted at: 1:01AM, 1:13AM and 1:29AM
Hall B visual checks conducted at: 1:00AM, 1:15AM and 1:30AM
Hall C visual checks conducted at: 1:00AM, 1:15AM and 1:30AM
Hall D visual checks conducted at 1:00AM, 1:15AM and 1:30AM
8/21/23:
Hall A visual checks conducted at: 12:58AM, 1:20AM, 1:32AM
Hall B visual checks conducted at: 1:00AM, 1:20AM and 1:38AM
Hall C visual checks conducted at: 1:00AM, 1:16AM and 1:30AM
Hall D visual checks conducted at: 1:01AM, 1:19AM and 1:29AM
All checks conducted within 30 minutes of each other.
Page 1 of 2

CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


summary:
Officers responded to the facility for a batter report. Staff 1 reported that on 7/7/23, Juvenile 1 struck him and pulled his hair repeatedly, requiring physical therapy for his neck.
Staff 1 reported that on 8/15/23, Juvenile 2 attacked him with a chair and kicked him on the “privates” after he corrected juvenile for exposing his genitals and making sexual comments/gestures towards staff.
Juvenile 1 attacked Staff 1 again on 8/15/23 by stabbing him on the arm with a pen. Staff 2 stated she attempted to take the pen away from the juvenile, who then struck her in the face and then bit her leg.
Staff 1 advised that there have been several other incidents between 7/7/23 and 8/15/23 and felt it was needed to file a police report for staff safety. Officers advised Staff 1 and Staff 2 on how to obtain a warrant.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2023-094595 JUVENILE INFORMATION Report generated: 9/2/2023 8:05 AM
Redact Before Release
NARRATIVE
OFFICERS RESPONDED TO THE METHODIST CHILDRENS HOME (2002 S FILLMORE) IN REFERENCE TO A BATTERY
REPORT
MR. PEARSON AND MS. FALLS ADVISED THAT THEY HAD BEEN ATTACKED BY BOTH JUVENILE 1 AND JUVENILE 2.
JUVENILE 1 FIRST ATTACKED MR. PEARSON ON JULY 7TH, 2023. MR. PEARSON ADVISED THAT JUVENILE 1 STRUCK
HIM AND THEN PULLED HIS HAIR FROM THE BACK REPEATEDLY. MR. PEARSON ADVISED THAT THE WAY IN WHICH
JUVENILE 1 PULLED HIS HAIR CAUSED INJURY TO HIS NECK THAT REQUIRED PHYSICAL THERAPY.
ON AUGUST 15TH AT APPROXIMATELY 1600 HOURS, JUVENILE 2 ATTACKED MR. PEARSON WITH A CHAIR TO THE
BODY AND THEN PROCEEDED TO KICK HIM ON THE "PRIVATES". MR. PEARSON ADVISED HE HAD TO CORRECT
JUVENILE 2'S BEHAVIOR AFTER JUVENILE 2 EXPOSED HIS GENITALS AND MADE SEXUAL COMMENTS AND
GESTURES TOWARDS OTHER STAFF MEMBERS.
JUVENILE 1 ATTACKED MR. PEARSON ONCE AGAIN ON AUGUST 15TH AT APPROXIMATELY 1730 HOURS. THIS TIME
IT WAS BY "STABBING" HIM WITH A PEN TO THE LEFT ARM. MR. PEARSON SHOWED OFFICER AN INJURY TO HIS
LEFT UPPER ARM CONSISTENT WITH BEING JABBED WITH A PEN. IT APPEARS THAT THE PEN BROKE THE SKIN BUT
DID NOT PENETRATE ANY FURTHER.
MS. FALLS ADVISED THAT SHE WITNESS THE ATTACK AND SHE ATTEMPTED TO TAKE THE PEN AWAY FROM
JUVENILE 1 BY REACHING FOR IT WHILE STANDING BEHIND JUVENILE 1. MS. FALLS ADVISED THAT JUVENILE 1
THEN TURNED AROUND AND STRUCK HER ON THE FACE, CAUSING IT TO BLEED. MS. FALLS ADVISED THAT
JUVENILE 1 THEN DROPPED TO THE GROUND AND PROCEEDED TO BITE HER LEG. MS. FALLS SHOWED OFFICERS
AN INJURY CONSISTENT WITH A BITE MARK TO HER LEFT UPPER LEG.
MR. PEARSON ADVISED THAT THERE HAVE BEEN SEVERAL OTHER INCIDENTS BETWEEN JULY 7TH AND AUGUST
15TH, BUT THESE TWO WERE SIGNIFICANT ENOUGH THAT HE FELT IT WAS NEEDED FOR HIM TO FILE A POLICE
REPORT FOR HIS AND THE OTHER STAFF MEMBERS SAFETY.
MR. PEARSON AND MS. FALLS ARE CARETAKERS AT THIS FACILITY (METHODIST CHILDRENS HOME). METHODIST
CHILDREN HOME IS A RESIDENTIAL TREATMENT FACILITY.
BOTH JUVENILE 1 AND JUVENILE 2 SUFFER FROM NEUROLOGICAL AND PHYSIOLOGICAL DISORDERS.
DHS HAS CUSTODY OF BOTH JUVENILE 1 AND JUVENILE 2.
MAJOR CRIMES WAS NOTIFIED AND AT THIS TIME IT IS NOT CLEAR THAT THE FACILITY AND THE WORKERS MEET
THE REQUIREMENTS FOR THE CHARGES TO BE ENHANCED TO FELONIES.
OFFICERS ADVISED MR. PEARSON AND MS. FALLS ON HOW TO OBTAIN A WARRANT IF THEY CHOSE TO DO SO.
OFFICERS PROVIDED MR. PEARSON AND MS. FALLS WITH AN INCIDENT NUMBER CARD.
MVR AND BWC WERE IN USE.
Page 8 of 9

doc_type: Police Report


summary: A monitor visit was conducted 8/16/23 and video was reviewed of random areas of the facility to check ratios.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/16/2023
Home Visit Date: 8/16/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Monitor visit conducted 8/16/23 and video reviewed of random areas of UMCH to check ratios.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

On 8/14/23:
Classroom 1130 staff/client ratio: 3:10
Classroom 2105 staff/client ratio: 3:7
Classroom 2106 staff/client ratio: 3:9
Cafeteria staff/client ratio: 5:17
Boy's Dayroom staff/client ratio: 4:11
On 8/15/23:
Cafeteria with female clients, staff/client ratio: 4:16
Cafeteria with male clients, staff/client ratio: 2:11
Classroom 1130 staff/client ratio: 3:9
Classroom 2105 staff/client ratio: 4:7
Classroom 2106 staff/client ratio: 2:9
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to review video of the early morning hours of 8/6/23 and 8/7/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/9/2023
Home Visit Date: 8/9/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 8/9/23 and video reviewed of the early morning hours of 8/6/23 and 8/7/23.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

8/6/23:
Hall A visual checks conducted at: 1:14AM, 1:28AM and 1:44AM
Hall B visual checks conducted at: 1:00AM, 1:15AM and 1:30AM
Hall C visual checks conducted at: 1:01AM, 1:16AM and 1:30AM
Hall D visual checks conducted at: 1:01AM, 1:15AM and 1:30AM
8/7/23:
Hall A visual checks conducted at: 1:13AM, 1:28AM and 1:45AM
Hall B visual checks conducted at: 1:13AM, 1:29AM and 1:44AM
Hall C visual checks conducted at: 1:00AM, 1:15AM and 1:30AM
Hall D visual checks conducted at: 1:00AM, 1:15AM and 1:30AM
All nightly visual checks conducted within 30 minutes.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to review video for the early morning hours of 7/29/23 – 7/30/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/1/2023
Home Visit Date: 8/1/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited from 10:45AM-12:00PM and random video review conducted for the early morning hours of
7/29/23 and 7/30/23.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

7/29/23:
Hall A visual checks conducted at 2:00AM, 2:15AM and 2:30AM
Hall B visual checks conducted at 1:59AM, 2:14AM and 2:29AM
Hall C visual checks conducted at 1:59AM, 2:14AM and 2:29AM
Hall D visual checks conducted at 1:59AM, 2:14AM and 2:29AM
7/30/23:
Hall A visual checks conducted at 1:59AM, 2:15AM and 2:30AM
Hall B visual checks conducted at 2:15AM, 2:30AM and 2:45AM
Hall C visual checks conducted at 2:02AM, 2:17AM and 2:30AM
Hall D visual checks conducted at 2:01AM, 2:16AM and 2:31AM
All night visual checks conducted within 30 minutes.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to review camera footage for the late night/early morning hours of 7/24/23 and 7/25/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/27/2023
Home Visit Date: 7/27/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 7/27/23 and camera footage reviewed for the late night/early morning hours of 7/24/23 and
7/25/23.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

7/24/23:
Hall A checks conducted at 12:01AM, 12:17AM and 12:29AM
Hall B checks conducted at 12:04AM, 12:17AM and 12:28AM
Hall C checks conducted at 12:00AM, 12:15AM and 12:31AM
Hall D checks conducted at 12:01AM, 12:16AM and 12:31AM
7/25/23
Hall A checks conducted at 12:02AM, 12:17AM and 12:32AM
Hall B checks conducted at 12:00AM, 12:15AM and 12:28AM
Hall C checks conducted at 12:00AM, 12:04AM and 12:15AM
Hall D checks conducted at 12:00AM, 12:04AM and 12:14AM
All night supervision checks conducted within less that 30 minutes.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: The juvenile victim’s grandmother called to report that she was at Children’s Hospital for an injury sustained in a fight at the facility. The victim stated that they suspect threw a chair at her and it hit her nose.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2023-085476 JUVENILE INFORMATION Report generated: 8/3/2023 11:42 AM
Redact Before Release
NARRATIVE
THE JUVENILE VICTIMS GRANDMOTHER, , CALLED TO REPORT THAT SHE WAS AT CHILDREN'S
HOSPITAL FOR AN INJURY SUSTAINED IN A FIGHT AT THE METHODIST CHILDREN'S HOME. I MADE CONTACT WITH
SHAWANDA MARTIN AND THE JUVENILE VICTIM. THE VICTIM SAID THAT THE SUSPECT THREW A CHAIR AT HER AND
IT HIT HER NOSE. SHE SAID THAT SHE DIDN'T KNOW IF IT WAS BROKEN OR NOT BUT SHE WAS BEING
DISCHARGED WHEN I ARRIVED. I ADVISED MS. MARTIN THAT IT WOULD BE CONSIDERED A BATTERY 3RD AND
WARRANTS COULD BE OBTAINED. THE GRANDMOTHER WAS NOTIFIED VIA COMMUNICATIONS.
Page 6 of 7


summary: A resident was sent to Arkansas Children’s Hospital for an x-ray of the face after a peer threw a chair, hitting the resident in the nose.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 7/26/2023
Date Received by DCCECE: United Methodist Children's Home Little Rock Campus
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On July 26, non DHS, was
sitting in the dayroom playing cards with her peers. Another client got up, picked up a chair
and threw it across the room hitting in the nose. was taken to Arkansas
Children's Hospital for an X-ray to the face. There was no findings of anything broken or
fractured. guardian is pressing charges on the other client, incident number for
this is
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/27/2023- Program Coordinator submitted a FOIA request to the
Little Rock PD for the incident report mentioned in this case.
Facility visited 7/27/23 and camera footage reviewed of incident involving client getting
hit in the nose by a chair thrown by another client. Staff/client ratio 3:13 in day area. Peer
who throws chair is calmly playing cards with another client. Peer calmly stands up, grabs a
plastic chair off a stack of chairs, and throws it in the middle of the day area. The chair
bounces and hits client who is laying in the floor. It appears as if looked up right as
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

the chair bounced in her direction. Staff immediately respond to peer who threw the chair
and client
Police report obtained regarding guardian pressing charges on client who threw the
chair. Email sent 7/28/23 to inquire if client was arrested for charges. Received email from
Craig Gammon of UMCH 7/28/23 as follows: I do not believe she was arrested. She was
admitted to acute hospitalization at after the incident. She has or will be
discharged from our program at MCH. The guardian of the injured client has contacted the
LRPD and is in the process of pressing charges, but we do not know the current status of
that action.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/27/2023
Home Visit Date: 7/27/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 7/27/23 and camera footage reviewed of incident involving client getting hit in the nose by a chair thrown
by another client. Staff/client ratio 3:13 in day area. Peer who throws chair is calmly playing cards with another client. Peer
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

calmly stands up, grabs a plastic chair off a stack of chairs, and throws it in the middle of the day area. The chair bounces and
hits client who is laying in the floor. It appears as if looked up right as the chair bounced in her direction. Staff
immediately respond to peer who threw the chair and client .
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.

raw_content:
July 24, 2023
The Division of Provider Services and Quality Assurance of the Arkansas Department of Human Services
has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care (IOC)
for Inpatient Psychiatric for Under 21. The Medicaid Manual for Inpatient Psychiatric Services for Under
Age 21 was used in the completion of this report.
Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the
following service site on the specified dates:
United Methodist Children’s Home
2002 South Fillmore Street
Little Rock, Arkansas 72204
Facility Provider ID:
Onsite Inspection Date: July 18, 2023
Onsite Inspection Time: 8:53 a.m.
A summary of the inspection and deficiencies noted are outlined below. The provider must submit a
Corrective Action Plan (CAP) designed to correct any deficiency notes in the written report of the IOC.
Accordingly, you must complete and submit to AFMC a Corrective Action Plan for each deficiency noted.
The Corrective Action Plan must state with the specificity the:
(a)Corrective action to be taken.
(b)Person(s) responsible for implementing and maintaining the corrective action; and
(c)Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report at
the link provided.
The contractor (AFMC) will:
(a)Review the Corrective Action Plan.
(b)Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c)Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance
(DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration
and appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of
Human Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff was promptly greeted at the locked entrance by a United Methodist
Children’s Home. AFMC was immediately taken to a conference room where they were met by the
Compliance Director and the Corporate Compliance Specialist. AFMC staff received the completed and
signed consent form listing approval for access to the AFMC portal prior to arrival for site visit.
A tour of the facility was completed with the Compliance Specialist. The facility environment was
extremely clean and well-organized. Since AFMC was last at this facility, they have increased their
census significantly and are now taking both male and female clients. According to the Compliance
Specialist, the census is averaging 30 or more clients between the ages of 12 and 17. There were no
environmental concerns noted during the tour. Educational classes and group activities were in session.
Several staff members were observed interacting calmly with clients in the classroom. Staff were able to
answer questions regarding the facility.
Facility Review-Policies and Procedures:
Upon review of the site’s policies and procedures, the following deficiencies were noted:
Rule Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: HR records did not indicate that all During the personnel record review
221.804; direct care personnel have ongoing it was noted that not all direct care
CFR 42 482.130, education, training, and demonstrated personnel have ongoing education,
483.376 knowledge of techniques to identify training, and demonstrated
staff and resident behaviors that may knowledge of techniques to identify
trigger an emergency safety situation staff and resident behaviors, events
semi-annually. and environmental factors that may
trigger emergency safety situations
on a semi-annual basis.
Personnel Records- Licenses, Certifications, Training:
There were fifteen personnel records requested, three (33%) professional staff and twelve (27%)
paraprofessional staff. During the review of the personnel records, the following deficiencies were noted:
Personnel Rule Credential Outcome Reviewer Notes
Record Validated
Number
SR014356 Medicaid IP Sec. 2: Restraint and Failed The provider lacked documentation
221.804; 42 CFR Seclusion of a Restraint and Seclusion training
482.130, 483.376 Training (CPI) refresher. CPI was last completed on
12/28/2022. The employee received
a warning from the provider on
07/17/2023, notifying them they
could not work until the refresher
was completed. The employee,
however, has been working with an
expired refresher and the last date
worked was 07/15/2023. The
provider noted that the employee is
scheduled for CPI training on July
30, 2023.
SR014130
United Methodist Children’s Home – Little Rock – IOC Report 2 | P ag e

The provider lacked documentation
of a Restraint and Seclusion training
refresher. CPI was last completed on
11/22/2022.
Clinical Summary
As a part of the Quality of Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list
was requested, client and/or guardian interviews were conducted, and a clinical record review was
completed. The following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client
interviews were conducted.
Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical
records reviews were conducted.
Program Activity/Service Milieu Observation:
Clients were observed in the classroom and in a group therapy session in the dayroom on the girl’s unit.
Staff were engaged with the clients and were providing a therapeutic environment that was conducive to
learning.
Medication Pass:
During the tour of the medication room, AFMC staff knocked on the medication room door. Facility staff
member opened door wearing cutoff jean shorts, t-shirt, and did not have an identification badge on.
When AFMC staff asked facility staff if they were the medication nurse, facility staff answered no.
AFMC staff asked to speak with the nurse who was giving medications to the client and this facility staff
then identified themselves as the medication nurse for this shift. AFMC staff voiced concern to the
Compliance Specialist regarding staff not having appropriate identification visible while administering
medications and medical care to clients. The Compliance Specialist stated that it is the facility’s policy
that all staff members wear an ID badge, and they will address this with the Director of Nursing
immediately.
No Medicaid clients received medications during medication pass. Due to the observation of non-
Medicaid clients not being complaint with the HIPAA minimal necessary rule, no medication pass was
observed. AFMC RN visited with the medication nurse who was able to show AFMC RN the facility
policies and procedures regarding medication administration, narcotic count/reconciliation/handling, and
medication discrepancies. Tour of medication room completed with a facility medication nurse and no
discrepancies with medication storage, cleanliness of medication room, and knowledge of medication
dispensing found.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report
available for review. The IOC Report and Request for Corrective Action can be accessed through the link
to AccessPoint, provided via email.
*For more details on the individual related deficiencies, please log into the portal.
United Methodist Children’s Home – Little Rock – IOC Report 3 | P ag e

Respectfully,
AFMC Inspection Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
United Methodist Children’s Home – Little Rock – IOC Report 4 | P ag e

doc_type: IOC Report


summary: Licensing conducted a visit to review timely night supervision checks.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/20/2023
Home Visit Date: 7/20/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Monitor visit conducted today to review timely night supervision checks. Halls A, B, C, D reviewed for the
early morning hours of 7/16/23 and 7/17/23.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

7/16/23:
Hall A checks conducted at 1:08AM, 1:14AM and 1:28AM.
Hall B checks conducted at 1:15AM, 1:30AM and 1:34AM.
Hall C checks conducted at 1:02AM, 1:20AM and 1:32AM.
Hall D checks conducted at 1:00AM, 1:15AM and 1:30AM.
7/17/23:
Hall A checks conducted at 1:27AM, 1:43AM and 1:57AM
Hall B checks conducted at 1:18AM, 1:30AM and 1:45AM
Hall C checks conducted at 1:00AM, 1:16AM and 1:31AM
Hall D checks conducted at 1:15AM, 1:31AM and 1:45AM
All night supervision checks done within 30 minutes.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: An x-ray was ordered after a resident twisted his ankle while playing in the gym.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 7/11/2023
Date Received by DCCECE: 7/12/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: ON July 11th, Female, goes by he/him
pronouns, age years and DOB , Empower insurance, family owned
kid, was in the gym playing in RT where "twisted" his ankle. An x-ray was ordered
and performed and the results are "No acute fracture"
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received report 7/12/23 that on July 11th,
Female, goes by he/him pronouns, was in the gym playing in RT where
"twisted" his ankle. An x-ray was ordered and performed, and the results are "No acute
fracture". No licensing concerns noted from this incident. Phone call made to Justin King of
UMCH to clarify "family owned kid" mentioned in facility report. Justin King indicated
that meant private placement.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident wrapped a pair of pants around her neck, stating “I want to kill myself.” Staff intervened and removed the pants. The facility was cited 907.2 and 907.3 due to staff not being present or supervising an escalated resident for 3 minutes.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 6/30/2023
Date Received by DCCECE: 6/30/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On June 30th 2023, about 6:45 am, client age DOB
DHS custody, was on the unit in active tantrum, yelling, screaming, attacking
staff. Staff removed other clients from the hallway, and during thi went into her
bedroom and grabbed a pair of pants and wrapped them around her neck, stating I want to
kill myself, staff intervened and removed the pants from the clients neck. was
assessed by the nurse and no markings were found. later in the morning was
transported by MEMS to the Behavioral Hospital in Maumelle.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received complaint 6/30/23 that on 6/30/23 client
made a suicidal gesture by wrapping a pair of pants around her neck. Client was
later transported to Maumelle Behavioral Hospital by MEMS. Email sent to facility 7/3/23
to inquire of video footage of this incident. Facility visited 7/5/23 in response to self-report
incident of client demonstrating suicidal behavior. Video reviewed of incident. Client
can be seen in a hall by herself, initially staff seen on the other side of a security access door
observing client. is seen spitting on bedroom doors and displaying escalated behavior. At
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

one point client can be seen entering her room and getting a cloth ligature and wrapping
it around her neck. Client can be heard saying she wants to die. About 3 minutes go by
with ligature wrapped around client's neck before staff enter the hallway and remove the
ligature. No staff could be seen supervising client on the other side of the door from this
camera angle. Camera footage of the other side of the security doors was reviewed for these
3 minutes. One staff is seen sitting in a chair outside of the security doors, not looking in on
client . Client was on a hall, by herself, escalated with no staff present on the hallway
for 3 minutes. Facility cited 907.2 and 907.3.

CORRECTIVE ACTION PLAN
Arkansas Department of Human Services Residential Licensing Unit
United Methodist Children's Home
Residential Treatment Centers| Qualified Residential Treatment Programs| Supervised Independent Living
** DISCUSSION/OBSERVATION**
Standard Reviewed: 9.907.2 and 9.907.3
Observation: Facility visited 7/5/23 in response to self-report incident of client demonstrating suicidal
behavior. Video reviewed of incident. Client can be seen in a hall by herself, initially staff seen on the
other side of a security access door observing client. is seen spitting on bedroom doors and displaying
escalated behavior. At one point client can be seen entering her room and getting a cloth ligature and
wrapping it around her neck. Client can be heard saying she wants to die. About 3 minutes go by with
ligature wrapped around client's neck before staff enter the hallway and remove the ligature. No staff could
be seen supervising client on the other side of the door from this camera angle. Camera footage of the other
side of the security doors was reviewed for these 3 minutes. One staff is seen sitting in a chair outside of
the security doors, not looking in on client Client was on a hall, by herself, escalated with no staff
present on the hallway for 3 minutes. Facility cited 907.2 and 907.3.
Corrective Action:
1. All staff will be retrained on the standards regarding supervision; ratio requirements and monitoring.
2. Retrain staff on the plan to call for help if monitoring becomes a problem at any time.
3. Retrain staff on policy and procedure regarding clients' supervision when on sick rule protocol,
hygiene, and isolation.
4. Implement a plan for Consultants (or other identified individuals) to randomly monitor and document
process for hygiene in the am and pm.
5. Review identified issues for possible disciplinary action. Video will be shown to the 1st shift staff
members for training purposes as well.
6. All incidents will be reviewed by Consultants and Director/Administrator and documented.
7. Review communication from Lead BI to how inaccurate information was reported to the Consultant on
call as evidenced by the discrepancy between the CIR and the video review; pants vs sweater, how
quickly staff intervened, and the staff to client ratio.
This plan is intended to address a trend in issues regarding the monitoring and supervision of clients
which has been noted in past months. The results of the plan and ongoing monitoring of issues will be
documented as well.
Identify Person Responsible: Director: , LCSW and Consultants, and

Completion Date:
1. __/__/____ as evidenced by Training Roster sign in sheet
2. __/__/____ as evidenced by Training Roster sign in sheet
3. __/__/____ as evidenced by Training Roster sign in sheet
4. __/__/____ : Create a form for monitoring hygiene process, via in person or video review and
implement the plan no later than Monday, July 10. A copy of the form will be attached to the
completed Corrective Action Plan.
5. __/__/____ as evidenced by Training Roster sign in sheet and Records of Supervision for each staff
member to include a plan for improvement in monitoring to be monitored and reviewed for progress
in a month.
6. __/__/____, on-going. All incidents are discussed in weekly staffings, including any changes that
will be made in the resident’s treatment, such as MTP problem/goal/objective additions; Addition
to Target Skills, etc. As evidenced by the Treatment Team Results note in the resident’s chart.
7. __/__/____ as evidenced by a Record of Supervision form.
Standard Reviewed: 9. 907. 6
Observation: Several videos reviewed (5) had more than 30 minutes in between checks.
Corrective Action:
1. Staff found to be out of compliance were addressed with disciplinary action.
2. All involved staff reviewed the requirement on timing and consistency of sleep time client checks.
This was found to be a compliance issue and not one resulting from lack of training.
3. A plan was implemented beginning on the evening of July 10th to correct these issues using the
following steps:
a. The use of timers was instituted on each residential sleeping unit. These timers are visual and
light up at preset times to alert staff that checks must be initiated. The timers’ audio feature can be
silenced so as not to disturb clients.
b. Video review of overnight checks on all units at random times is now conducted a minimum of
three times per week. This is scheduled and completed by the Supervisors, Director and or Administrator.
c. Any observations indicating lack of compliance are immediately addressed with appropriate
actions.
d. This plan will continue for a minimum of 60 days and or until consistent compliance is
observed.
4. In-person, drop-in visits to the facility during sleep hours will be increased and will be conducted by
supervisors or administrative staff.
Completion Date:
1. 7/17/23 Warning reports issued to non-compliant staff and submitted to personnel file.
2. 7/10/23 Completed in person and via email with instructions on use of timers etc.
2

3. 7/10/23 Use of timers implemented for 3rd shift and 5th shift on this date. Verified visually by video
review. Timers are visible by cameras while in use.
4. 7/10/23 plan completed during meeting of RTC management team, these visits are unscheduled but
will be documented as they randomly occur.
Identify Person Responsible: Director: , LCSW and Consultants, and
, Administrator, .
3


summary: Officers responded to the facility for a runaway report. Upon arrival, officer made contact with a staff member who advised that a juvenile ran away from the facility.

raw_content:
LITTLE ROCK POLICE DEPARTMENT INCIDENT REPORT

Report,generated: 6/26/2023 12:22 PM
MA LLO E OF CALL

MISPER

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME) DISTRICT
2002 S FILLMORE ST

6/24/2023 4:22:34 PM 54

METHODIST HOME

INCIDENT OFFENSE TYPE OFFENSE STATUS

Attempted
1, RUNAWAY ; Cmpiend EF 2 FE 3 H 4 H

Attempted

Completed sH ‘H "H *H
SUSPECTS USED: TYPE OF CRIMINAL ACTIVITY; GANG RELATED INFO:
((A) Alcohol (_]() Drugs (18) Buying / Receiving [1(©) Cultivate / Manufacture / Publish (10) Juvenile Gang
CA) Computer Equip wm Not Applicable / (-1() Exploiting Children (Jc) Operating / Promoting / Assisting [J(G) Other Gang

Unknown (11) Transport / Transmit / Import [7](U) Using / Consuming (0) None/ Unknown
Oo) Distributing / Selling CO (P) Possessing / Concealing

LOCATION CODE; (](16) Lake / Waterway [)(4) Daycare Facility [_](S1) Rest Area
mC) Air / Bus / Train Terminal Ca7) Liquor Store (](45) Dock / Wharf / Freight Terminal [-1(52) School - College / University
{-](02) Bank / Savings & Loan [_](18) Parking Lot / Garage [1 (46) Farm Facility [](53) School - Elementary / Secondary
C (03) Bar / Night Club Jas) Rental / Storage Facility Oo (47) Gambling / Casino / Racetrack 54) Shelter - Mission / Homeless
Oo (04) Church / Synagogue / Temple (20) Residence / House CJ (48) Industrial Site Css) Shopping Mall
(_] 05) Commercial / Office Building (21) Restaurant [-](49) Military Installation (-](56) Tribal Lands
(J) 06) Construction Site Oo (22) School / College (1 (50) Park / Playground ]s7) Community Center
oO (07) Convenience Store (-J(23) Service / Gas Station
(£1) (08) Department / Discount Store (_](24) Specialty Store (TV, Fur, Etc)
[] (09) Drug Store / DR Office / Hospital [7](25) Other / Unknown WEAPON FORCE: (on! 1-15, an"A° denotes Automatic or Sem!-Automatic)
[J 10) Field / Woods [](37) Abandoned/Condemned Structure (1) Firearm (Unknown) (160) Poison
[](11) Government / Public Building (18) Amusement Park ~ (a2) Handgun [J (60) Explosives
(112) Grocery / Supermarket (1039) Arena / Stadium / Fairgrounds — (J(3) Rifle [J(5) Fire / Incendiary Device
(13) Highway / Road / Alley (140) ATM Separate from Bank _ (04) Shotgun om Narcotics / Drugs /
(114) Hotel / Motel / Ete [1@1) Auto Dealership New / Used (JS) Other Firearm Sleeping Pills
(5) Jail / Penitentiary (142) Camp / Campground Deo) Knife / Cutting Instr (Axe, etc) (1085) Asphyxiation
(160) Blunt Object (Club, etc) Lo) Other
(FOR BURGLARY ONLY) METHOD OF ENTRY: (1635) Motor Vehicle (as weapon) (1095) Unknown

NUMBER OF PREMISES ENTERED oO (F) Forcible [](N) No Force [-1(40) Personal Weapons (hands, etc) (199) None

NARCAN USED: []yes [[JNo [[Jother

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR

06/24/2023 22:04:00 | NICOLE NOEL J SYLWIA CARRIG (IMVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page | of 5

INCIDENT NUMBER 2023-071380 NGAP LOFMAtON Report generated: 6/26/2023 12:22 PM

OTHER PERSONS - PERSON REPORTING

OTHER PERSON # | NAME (Last, First, Middle)
1 RUDLEY, RICHARD
ADDRESS;
2002 S FILLMORE ST LITTLE ROCK AR 72204

HOME PHONE: WORK PHONE: MOBILE PHONE: OTHER PHONE:
5019064913

SEX: [¥](M) Male ETHNICITY: [[](H)Hispanic RACE: [_](W) White [Z](B) Black [_](1) American Indian | DATE OF BIRTH
(C1) Female = [[](U) Unk. } [¥](N) Non-Hispanic (vy unk. (1A) Asian / Pacific Islander [[](U) Unknown 01/30/1980

RES. STATUS: — [_](R) Resident MENTALLY AFFLICTED? OCCUPATION / EMPLOYER:
LJ(N) Nonresident [¥](U) Unknown | [](y) Yes (]J(N) No [[](U) Unk.

AGE: 4 HEIGHT;
Exact Age: 43 Ft
Range: - Cap) 7-364 Days Old

Mm) Under 24 Hrs. Old C99) Over 98 Years Old D.L. / ID No. (STATE) WEIGHT:
Cans) 1-6 Days Old (100) Unknown Lbs

COMPLEXION: HAIR STYLE: HAIR COLOR: FACAIL HAIR: DEMEANOR: SCAR / MARK: TATTOO:

(1) Light [](01) Afro (](1) Black (-](01) Clean Shaven — [_] (01) Angry (01) Head [_](1) Designs
(2) Medium — [_](02) Wavy (2) Blonde (02) Unshaven [_](02) Apologetic (02) Neck (2) Initials
(3) Dark (03) Straight (3) Brown (03) Full Beard (03) Calm (03) Hand (rt) (3) Names
(4) Acne (04) Curly (4) Grey (4) Pictures

(5) Freckled (05) Braided (5) Red [_](05) Must, (thin) (05) Nervous

[_](6) Ruddy (06) Ponytail [_](6) Sandy (06) Brows (hvy) (06) Polite
(7) Other (07) Military (7) Other (07) Brows (thin) a Professional

(05) Arm (rt) (5) Words
(06) Ann (Ift) (6) Numbers
(07) Body (7) Insignia
(08) Leg (rt) (8) None
(09) Leg (lft) (9) Unknown

(8) Unknown (08) Processed (8) Unknown (08) Side Burns (08) Stupor
: (09) Wig/Toupee : (09) Goatee (09) Violent
HAIR LENGTH: [7}(10) Other EYE COLOR: (10) Other (10) Drunk / High (10) Other j
TATTOO LOC:
(](1) Long [](11) Unknown (_](1) Blue (11) Unknown (11) Other (11) None
(2) Medium A Brown {_]12) Unknown (12) Unknown les Amn (Ift)

(04) Must. (hvy) (04) Irrational He Hand (Ift)

(3) Short BUILD: (3) Grey (02) Arm (rt)
(4) Bald(ing) [[](1) Light (4) Green (03) Leg (Ift)
. (5) Other [_](2) Medium (5) Hazel Boe Leg (rt)
(6) Unknown (3) Heavy (6) Other (05) Hand (Ift)
A Muscular (7) Unknown ala BESET (06) Hand (rt)
(5) Unknown EOE ——————— (07) Face
COAT SSS (08) Neck
SHIRT sss (09) Finger(s)
PANT S/R SS a (10) Chest
SHOES a a (11) Back

Page 2 of 5

INCIDENT NUMBER 2023-071380

OTHER PERSONS - RUNAWAY

OTHER PERSON # | NAME (Last, First, Middle)
2

ADDRESS:
2002 S FILLMORE ST LITTLE ROCK AR 72204

HOME PHONE: WORK PHONE: MOBILE PHONE: OTHER PHONE:

SEX: [¥](M) Male
(J) Female —[](U) Unk.

RACE: [](W) White [¥](B) Black [[](1) American Indian
(tA) Asian / Pacific Islander [7] (U) Unknown

DATE OF BIRTH

ETHNICITY: [_](H)Hispanic
[ZJ(N) Non-Hispanic [[](U) Unk.

RES. STATUS: _ [¥](R) Resident
(J) Nonresident [7](U) Unknown

MENTALLY AFFLICTED?
CUcy) Yes yy No [](v) unk.

OCCUPATION / EMPLOYER:

AGE:
Exact Age: 15
Range:

(Nn) Under 24 Hrs. Old
(Jans) 1-6 Days Old

HEIGHT:

Ft
(_](BB) 7-364 Days Old
[](99) Over 98 Years Old
(1100) Unknown

D.L. / ID No, (STATE)

TATTOO;

COMPLEXION:
(1) Light
| _](2) Medium
| |(3) Dark
(4) Acne
(5) Freckled
(6) Ruddy
(7) Other
(8) Unknown

HAIR LENGTH:

(2) Medium

(4) Bald(ing)
|] (5) Other
| _|(6) Unknown

HAIR STYLE;

(01) Afro
(02) Wavy
(03) Straight

(04) Curly

|_](05) Braided

| _](06) Ponytail
(07) Military
(08) Processed
(09) Wig/Toupee
(10) Other
(11) Unknown

BUILD;

(1) Light
(2) Medium
(3) Heavy

(4) Muscular
[_](5) Unknown

HAIR COLOR;
(1) Black

| _](7) Other
|_}(8) Unknown

EYE COLOR:
(1) Blue

|_|(2) Brown

(3) Grey
(4) Green
(5) Hazel

[_]©) Other
CJ (7) Unknown

FACAIL HAIR;

(01) Clean Shaven
(02) Unshaven

(03) Full Beard
(04) Must. (hvy)
(05) Must. (thin)
(06) Brows (hvy)
(07) Brows (thin)
(08) Side Bums
(09) Goatee
(10) Other
[¥](11) Unknown

DEMEANOR:

(01) Angry
(02) Apologetic

(03) Calm

(04) Irrational

(05) Nervous

(06) Polite

(07) Professional
| ](08) Stupor
(09) Violent
|_|(10) Drunk / High
|_}(11) Other
(12) Unknown

CLOTHING DESCRIPTION

HAT
COAT
SHIRT

WHITE MONEY SHIRT

PANTS/DRESS _BLACK PANTS

SHOES

SCAR / MARK;

(701) Head
(02) Neck
(03) Hand (rt)
(04) Hand (If)
(05) Arm (rt)
(06) Arm (If)
(07) Body
(08) Leg (rt)

[_](09) Leg (Ift)

(10) Other
(11) None
(12) Unknown

H 1) Designs

(2) Initials
(3) Names
(4) Pictures
(5) Words
(6) Numbers
(7) Insignia
(8) None
(9) Unknown

TATTOO LOC:

(01) Arm (Ift)
(02) Arm (rt)
[_](03) Leg (if)
[_](04) Leg (rt)
(05) Hand (Ift)
(06) Hand (rt)
(07) Face
(08) Neck
(09) Finger(s)
(10) Chest
(11) Back

Page 3 of 5

INCIDENT NUMBER 2023-071380

ATOTMALION — Report generated: 6/26/2023 12:22 PM

NARRATIVE

OFFICERS RESPONDED TO THE LISTED LOCATION FOR A RUNAWAY REPORT. UPON ARRIVAL OFFICER MADE

CONTACT WITH RICHARD RUDLEY, HOUSE MANAGER OF METHODIST CHILDREN'S HOME, WHO ADVISED DURING
THE ABOVE DATE AND TIMES JUVENILE RAN AWAY FROM THIS LOCATION.

OFFICER ENTERED JUVENILE 1 INTO ACIC ENTRIES AND DELETIONS AS A RUNAWAY/MISSING PERSON.
MVR AND BWC IN USE.

Page 4 of 5

INCIDENT NUMBER 2023-071380 eport ORARNIR: CRAP LOFMALION — Report generated: 6/26/2023 12:22 PM
5 B .

ADDITIONAL HOMICIDE CIRCUMSTANCES me) Criminal attacked a civilian Oe) Criminal resisted arrest

CJ (A) Criminal attacked police officer, that officer killed criminal Qo) Criminal attempted flight from a crime o® Unable to determine /
Oo (B) Criminal attacked police officer, criminal killed by other officer O (E) Criminal killed in commission of a crime not enough information

RELATED CASE NUMBER(S)
CAR JACKING? [_JYES [¥]NO DRIVE-BY? [JYES [7]NO GANG RELATED? [_]YES [¥]NO

HATE/BIAS RELATIONSHIP: _[¥](88) None [J YES, SEE BELOW
RACIAL (Anti-) RELIGIOUS (Anti-) ETHNICITY / NATIONAL ORIGIN (Anti-) SEXUAL (Anti-)

Cd 1b white (021) Jewish [_](32) Hispanic [](41) Male Homosexual (Gay)
(12) Black (](22) Catholic (1633) Other Ethnicity [_] (42) Female Homosexual (Lesbian)
(13) American Indian / (23) Protestant x (43) Homosexual (Gay and Lesbian)
CO] Alaskan Native Hy (24) Islamic (Muslim) BRASIL S ey H (44) Heterosexual
(_](14) Asian / Pacific Islander (](25) Other Religion [](51) Physical Disability (J (45) Bisexual
{_](15) Multi-Racial Group (_](26) Multi-Religious Group [_](52) Mental Disability
(J(27) Atheist/Agnostic

Page 5 of 5


summary: A staff member grabbed a resident from the back, pushing him into a bookshelf and making him hit his head while trying to separate the resident from his peers during a physical altercation. The staff member was terminated. The facility was cited 905.4.d, 905.4.g, 109.1.g, and 907.2 as a result of this incident.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 6/22/2023
Date Received by DCCECE: United Methodist Children's Home Little Rock Campus
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Dual
Report Description: , DHS placement was in the classroom
refusing to go sit at his desk. (staff) began using the Teaching Family
Model to teach to the youth behavior, but continue to ignore her instructions.
sat in the chair in front of and began going back and forth with
each other. One client ( involved himself attempting to take up for
getting in face and hit him in the face. (staff) got between
and to separate the clients. took out of the room, while is
separating that incident and is still going back and forth.
(client) gets involved trying to attack and intervene by stepping in
front of the client. (client) gets up a second time walks in personal space and
kicks him. As and is seperating the and charge
toward and kicks him. The staff goes to break the two clients the client
goes over to and spits on him. intervene by guiding out of the
room. walks over to the bookshelf, (staff) runs over stating "don't touch",
grabs the clients from the back pushing him against the shelf making him hit his head.
then slung over on the desk, then punches her in the face. is
now trying to prevent client from hitting her, (staff) comes over to help seperate the
from still have a hold of shirt while (staff) is trying
to place him in a hold. then grabs one of legs, at this time is on the
floor. release his leg yelling "calm down". (client) runs up kicks
and pour water on him. A report was called in and accepted. The report number is
Corrective Action Plan: was terminated. We will do an in-service
with and other staff members on tantrum management and the crisis
development model.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative: Corrective Action Plan: was terminated. We will
do an in-service with and other staff members on tantrum management and the
crisis development model.
Maltreatment Narrative: Ref# Received email notification 9/5/23 that
maltreatment complaint was unfounded.
Licensing Narrative: Licensing received complaint 6/23/23 that on 6/22/23 staff
shoved client during an incident. was
called, ref# . Corrective Action Plan: was terminated. We will do
an in-service with and other staff members on tantrum management and the
crisis development model. 6/26/23- Program Coordinator emailed the investigator for
permission to contact the agency. Facility visited 6/27/23 in response to complaint that staff
had inflicted physical harm to a client during an altercation. Video
reviewed of classroom where incident took place. Staff and client can be heard
exchanging words. At one point client calls staff a b*itch to which she replied "it
takes one to know one"-facility cited 905.4d: The following disciplinary actions shall not be
used-b) Derogatory comments about the child, the child's family, race or gender. Two other
peers periodically attempt to physically engage during this conversation. Male staff
is present and attempts to prevent the other peers from attacking At one point
staff does not intervene and allows another peer to kick Facility cited 907.2-
Childcare staff shall be responsible to providing the level of supervision, care and treatment
necessary to ensure the safety and well-being of each child at the facility. is seen
standing be a metal bookshelf, turned around facing the bookshelf, seemingly touching
something staff does not want to touch. Staff runs towards grabs him
by his shoulders, head is seen and heard hitting the metal bookshelf. Facility cited
109.1g-Unprofessional conduct in the practice of child welfare activities shall include
without limitation-g) Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children. Facility cited 905.4g-The following
disciplinary actions shall not be used g) Physical injury or threat of bodily harm. After
pushing into the bookshelf attempts to swing at staff face. Staff
intervenes as to separate client and staff at this time. Staff is seen putting
her hand on the back of neck and pulling leg during the altercation. At no time is
staff seen attempting to initiate a restraint. Staff was given in-service
retraining from UMCH staff Sherika Williams on 6/23/23. Staff was
terminated from employment at UMCH following this incident. 8/3/2023- Maltreatment
case is still open and pending. 9/5/23-Maltreatment case unfounded.


summary: A resident grabbed a staff member’s keys, ran through the unit and eloped from the facility. Another resident ran as well but returned with the keys a moment later.

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keys 1 minute later. The local police were notified immediately, and they are still looking for
the client. Facility visited 6/20/23 and video reviewed of elopement. Staff/client ratio in
video 1:3. is seen and heard having conversation with staff about her ( s)
keys, when grabs keys from staff and use key fob to exit area, another peer following
behind him. The other peer had grabbed staff's radio and pushed door closed behind him
when exiting area. Staff immediately tried to chase clients but was unable to exit door
to pursue them. Clients are seen in video exiting the hallway then into the courtyard where a
key fob would have granted them access out of the courtyard. The peer with is then seen
using the key fob to re-enter facility and giving the keys back to staff. Staff did not fail to
supervise clients until clients eloped during video reviewed. Staff did not properly secure
keys/key fob while supervising clients. Staff will complete in-service on importance
of key/key fob control. Staff in-service training emailed to licensing 6/21/23.
Received email from Justin King 6/26/23 of UMCH that client was located and brought
to UMCH on 6/25/23. Email received 6/26/23 from UMCH as follows: Good afternoon, we
don't have a written safety plan. We have a doctor's order that we are abiding by. The
doctors order are Elopement Precaution, Building Restriction, Unit Restriction and 60k
focus.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 6/20/2023
Home Visit Date: 6/20/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 6/20/23 and video reviewed of elopement. Staff/client ratio in video 1:3. is seen and heard having
conversation with staff about her ( 's) keys, when grabs keys from staff and uses key fob to exit area, another
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

peer following behind him. The other peer had grabbed staff's radio and pushed door closed behind him when exiting area.
Staff immediately tried to chase clients but was unable to exit door to pursue them. Clients are seen in video exiting the
hallway then into the courtyard where a key fob would have granted them access out of the courtyard. The peer with is
then seen using the key fob to re-enter facility and giving the keys back to staff.
Staff did not fail to supervise clients until clients eloped during video reviewed. Staff did not properly secure keys/key fob
while supervising clients.
Staff will complete in-service on importance of key/key fob control. in-service training emailed to licensing
6/21/23.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Officers responded to a runaway juvenile report at the facility. Officers located the resident days later and transported the resident back to the facility.

raw_content:
LITTLE ROCK POLICE DEPARTMENT INCIDENT REPORT

[ZJJUVENILE INFORMATION Report,generated: 7/9/2023 12:45 PM
WO DO Oa he LOL

INCIDENT NUMBER

2023-068255

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME) DISTRICT

2002 S FILLMORE ST

6/17/2023 1:17:59 PM 54

INCIDENT OFFENSE TYPE OFFENSE STATUS

Attempted | |
1, RUNAWAY Compteted 1 2 H 3 H 4 4

Attempted

Completed 5H “H "A ‘H
SUSPECTS USED: TYPE OF CRIMINAL ACTIVITY; GANG RELATED INFO:
CI) Alcohol (]() Drugs (@) Buying / Receiving (1) Cultivate / Manufacture / Publish (10) Juvenile Gang
[J(C) Computer Equip rah et Applicable / (18) Exploiting Children (_](©) Operating / Promoting / Assisting (1G) Other Gang

Unknown Om Transport / Transmit / Import mw) Using / Consuming Ow) None / Unknown
Cw) Distributing / Selling Oe) Possessing / Concealing

LOCATION CODE: (16) Lake / Waterway (]44) Daycare Facility (1651) Rest Area
(C10) Air / Bus / Train Terminal (J(17) Liquor Store [](45) Dock / Wharf/ Freight Terminal [7](52) School - College / University
(-] (02) Bank / Savings & Loan ([] 18) Parking Lot / Garage [-] (46) Farm Facility [£1(53) School - Elementary / Secondary
(-] 3) Bar / Night Club O (19) Rental / Storage Facility oO (47) Gambling / Casino / Racetrack C64) Shelter - Mission / Homeless
[J (04) Church / Synagogue / Temple (20) Residence / House (_](48) Industrial Site (21655) Shopping Mall
{](05) Commercial / Office Building (_] (21) Restaurant (149) Military Installation (2156) Tribal Lands
{_] (06) Construction Site [_] (22) School / College (1(50) Park / Playground (157) Community Center
[_](07) Convenience Store [-] (23) Service / Gas Station
[] (08) Department / Discount Store (-](24) Specialty Store (TV, Fur, Etc)
[_] (09) Drug Store / DR Office / Hospital [7] (25) Other / Unknown WEAPON FORCE: — (on I I-15, an "A" denotes Automatic of Semi-Automatic)
(10) Field / Woods (_](37) Abandoned/Condemned Structure (1) Firearm (Unknown) (1650) Poison
(10.1) Government / Public Building {]38) Amusement Park _ (02) Handgun [_] 0) Explosives
() 12) Grocery / Supermarket [_](39) Arena / Stadium / Fairgrounds ~ (3) Rifle Cs) Fire / Incendiary Device
(11:3) Highway / Road / Alley [](40) ATM Separate from Bank __ (4) Shotgun me Narcotics / Drugs /
(14) Hotel / Motel / Ete ([)(41) Auto Dealership New / Used [J5) Other Firearm Sleeping Pills
(15) Jail / Penitentiary (-] 42) Camp / Campground Deo) Knife / Cutting Instr (Axe, ete) [J(85) Asphyxiation
(£10) Blunt Object (Club, ete) (190) Other
(FOR BURGLARY ONLY) METHOD OF ENTRY: (135) Motor Vehicle (as weapon) (105) Unknown

NUMBER OF PREMISES ENTERED Ce Forcible [av No Force (140) Personal Weapons (hands, etc) (099) None

NARCAN USED: Cyves (JNo {_]Other

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR MVRi
06/17/2023 19:23:03 | CHRISTOPHER FLOWERS [i BRITTNEY JACKSON [i ica

LRPD Form 5501-01 Rey. RMS-2019-01-23 Page | of 5

INCIDENT NUMBER 2023-068255

OTHER PERSON #
1

NAME (Last, First, Middle)

ADDRESS:
2002 S FILLMORE ST LITTLE ROCK AR 72205

MOBILE PHONE:

OTHER PHONE:

DATE OF BIRTH

HOME PHONE: WORK PHONE:

RACE: [Z](W) White [[](B) Black [[]() American Indian
(1A) Asian / Pacific Islander [_](U) Unknown

SEX; [¥](M) Male
(J) Female = [[](U) Unk.

ETHNICITY: [_](H)Hispanic
[Z](N) Non-Hispanic [7](U) Unk,

RES, STATUS: [Z](R) Resident MENTALLY AFFLICTED? OCCUPATION / EMPLOYER:

CJ(N) Nonresident [](U) Unknown | [¥](Y) Yes [[J(N) No [[](U) Unk.

AGE:
Exact Age: 14
Range:

[J (NN) Under 24 Hrs, Old
Cn) 1-6 Days Old

HEIGHT:

Ft
()(BB) 7-364 Days Old
C9) Over 98 Years Old
(-J(00) Unknown

D.L. / ID No. (STATE) WEIGHT:

COMPLEXION:
|} (1) Light

(2) Medium
(3) Dark

(4) Acne

(5) Freckled
(6) Ruddy
(7) Other

(8) Unknown

HAIR LENGTH:

(1) Long
wv} (2) Medium
(3) Short

(4) Bald(ing)
(5) Other
(6) Unknown

HAIR STYLE;

| _|(01) Afro

| |(02) Wavy

(03) Straight

| |(04) Curly

|_| (05) Braided

(06) Ponytail
(07) Military
(08) Processed
(09) Wig/Toupee
(10) Other

Oa 1) Unknown

BUILD:
(1) Light
(2) Medium

(3) Heavy
(4) Muscular
(5) Unknown

HAIR COLOR:
| 1(1) Black

| _|(2) Blonde
(3) Brown

[_](5) Red
[_](6) Sandy

(7) Other

(8) Unknown

EYE COLOR:

| |(4) Green
| |(5) Hazel
| |(6) Other
|_|(7) Unknown

SCAR / MARK:

FACAIL HAIR:

(01) Clean Shaven

|_](02) Unshaven

| |(03) Full Beard
(04) Must. (hvy)
(05) Must. (thin)
(06) Brows (hvy)
(07) Brows (thin)
(08) Side Burns
(09) Goatee
(10) Other
(11) Unknown

DEMEANOR;

(01) Angry O
(02) Apologetic
{_](03) Calm

(04) Irrational
(05) Nervous
(06) Polite

{] (07) Professional
| |(08) Stupor

| _|(09) Violent
__|(10) Drunk / High
| |(11) Other

(12) Unknown

CLOTHING DESCRIPTION

HAT

COAT

SHIRT
PANTS/DRESS
SHOES

PINK HOODIE WHITE HOODIE
WHITE SHIRT

BLUE SHORTS

RAINBOW SHOES/SOCKS

(01) Head

(02) Neck
(03) Hand (rt)
(04) Hand (If)
(05) Arm (rt)
(06) Arm (Ift)
(07) Body
(08) Leg (rt)
(09) Leg (ft)
(10) Other
(11) None
(12) Unknown

TATTOO;

Ola ) Designs
(2) Initials
(3) Names
(4) Pictures
(5) Words
(6) Numbers
(7) Insignia
(8) None

Le) Unknown

TATTOO LOC:

(01) Arm (Ift)
(02) Arm (rt)
Hie.) Leg (Ift)
(04) Leg (rt)
(05) Hand (Ift)
(06) Hand (rt)
(07) Face
(08) Neck
(09) Finger(s)
(10) Chest
(11) Back

Page 2 of 5

INCIDENT NUMBER 2023-068255

AFOFMALION — Report generated: 7/9/2023 12:45 PM

OTHER PERSONS - CONTACT

OTHER PERSON #
2

NAME (Last, First, Middle)

ADDRESS:

HOME PHONE:
5016610670

SEX: [¥](M) Male
[(F) Female [[](U) Unk.

RES.STATUS: — [¥](R) Resident
[-J(N) Nonresident [[](U) Unknown

AGE:

Exact Age: 41
Range:

[_J«NN) Under 24 Hrs, Old
(ns) 1-6 Days Old

(ep) 7-364 Days Old
(1099) Over 98 Years Old
(100) Unknown

COMPLEXION: HAIR STYLE:

(J) Light Hm Afro

HAIR COLOR;
[_](1) Black
(2) Blonde
(3) Brown
(4) Grey
(5) Red
(6) Sandy

(2) Medium (02) Wavy
(3) Dark (03) Straight
(4) Acne (04) Curly
(5) Freckled (05) Braided

ETHNICITY: [[](H)Hispanic
[Z](N) Non-Hispanic [_](U) Unk.

MENTALLY AFFLICTED?
Cy) Yes (JN) No [-](u) unk.

(J(A) Asian / Pacific Islander (](v) Unknown

OCCUPATION / EMPLOYER:

HEIGHT:

Ft

D.L./ ID No, (STATE) WEIGHT:

SCAR / MARK:

[](01) Head

[_] (02) Neck
(03) Hand (rt)
(04) Hand (Ift)
(05) Arm (rt)
(06) Arm (lft)

FACAIL HAIR: DEMEANOR:

(01) Clean Shaven (01) Angry
(02) Unshaven (02) Apologetic
(03) Full Beard (03) Calm

(04) Must. (hvy) [_] (04) Irrational
(05) Nervous
(06) Polite

RACE: [[](W) White [](B) Black [_](1) American Indian

|_|(7) Other

(8) Unknown

HAIR LENGTH:

[J (1) Long

(07) Military
(08) Processed
| _|(09) Wig/Toupee
| _|(10) Other
(11) Unknown

(6) Ruddy Een Ponytail

|_|(7) Other

(8) Unknown

EYE COLOR:
(J) Blue

(05) Must. (thin)
(06) Brows (hvy)
(07) Brows (thin)
_|(08) Side Bums
| _|(09) Goatee
| |(10) Other
(11) Unknown

LJ (07) Professional

(08) Stupor

(09) Violent

(10) Drunk / High
[_](11) Other

(09) Leg (lft)
(10) Other
(11) None

(2) Medium (2) Brown
(3) Short BUILD: (3) Grey
(4) Bald(ing) (1) Light (4) Green
| _|(5) Other (2) Medium (5) Hazel
(6) Unknown (3) Heavy (6) Other
(4) Muscular [v]}(7) Unknown
[]6) Unknown

(07) Body
(08) Leg (rt)

[¥] (12) Unknown (12) Unknown

CLOTHING DESCRIPTION
HAT

COAT

SHIRT

PANTS/DRESS

SHOES

DATE OF BIRTH
07/11/1981

TATTOO:
(J() Designs

(2) Initials
(3) Names
(4) Pictures

(5) Words
(6) Numbers
(7) Insignia
(8) None
[_](9) Unknown

TATTOO LOC:

(01) Arm (Ift)
(02) Arm (rt)
(03) Leg (Ift)
(04) Leg (rt)
[_] (05) Hand (1ft)
(06) Hand (rt)
(07) Face
(08) Neck
(09) Finger(s)
(10) Chest
(J (11) Back

Page 3 of 5

INCIDENT NUMBER 2023-068255 ( ; Pro TOFMALLON Report generated: 7/9/2023 12:45 PM

NARRATIVE

ON JUNE 17, 2023, OFFICERS RESPONDED TO A RUNAWAY JUVENILE REPORT AT 2002 S FILLMORE ST. UPON
ARRIVAL OFFICERS MADE CONTACT WITH METHODIST CHILDREN HOME MANAGER, MR, ERIC LOWE, MR. LOWE
ADVISED AT APPROXIMATELY 1:00 PM, JUVENILE 1 EXITED THE BACK DOOR OF THE FACILITY AND FLED WEST
TOWARD UNIVERSITY. MR. LOWE ALSO ADVISED THE JUVENILE TOLD ONE OF THE RESIDENTS HE WAS GOING
BACK TO MAGNOLIA, AR. OFFICERS NOTIFIED SUPERVISOR AND CONDUCTED BROADCAST OF JUVENILES
DESCRIPTION AND LAST KNOWN DIRECTION OF TRAVEL. OFFICERS CIRCULATED THE AREA WITH NEGATIVE
RESULTS. OFFICERS COMPLETED SUPPLEMENT FORM AFTER COMPLETING SEARCH OF THE AREA. BWC IN USE.

**SUPPLEMENTAL INFORMATION**
PERSON1 WAS ENTERED INTO ALL SYSTEMS AS MISSING.
06/17/2023 1524 HOURS K. NORWOOD COMM.

“1X54 C.FLOWERS 06/25/2023**

2023-71705

ON JUNE 2, 2023, OFFICERS RESPONDED TO A DISTURBANCE AT 3618 W ROOSEVELT. WHILE ON SCENE OFFICERS
NOTICED A SUBJECT IN THE AREA FITTING THE DESCRIPTION OF A RECENT RUNAWAY JUVENILE. OFFICERS MADE
CONTACT AND CONFIRMED RUNAWAYS IDENTITY. OFFICERS TRANSPORTED RUNAWAY BACK TO METHODIST
CHILDREN HOME AND TRANSFERRED CUSTODY TO THE FACILITY MANAGER, MR. ERIC TEMPLE. OFFICERS
NOTIFIED ACIC/NCIC DELETIONS, BWC IN USE.

******* SUPPLEMENTAL INFORMATION"****"HICKSJIMIMIN 6/25/2023
COMMUNICATIONS CLEARED RUNAWAY FROM ACIC

Page 4 of 5

INCIDENT NUMBER 2023-068255 MAP TOTIMALION — Report generated: 7/9/2023 12:45 PM

ADDITIONAL HOMICIDE CIRCUMSTANCES O (C) Criminal attacked a civilian Ce) Criminal resisted arrest

[_](A) Criminal attacked police officer, that officer killed criminal [_](D) Criminal attempted flight from a crime Ooo Unable to determine /
[_](B) Criminal attacked police officer, criminal killed by other officer (](E) Criminal killed in commission of a crime not enough information

RELATED CASE NUMBER(S)
CAR JACKING? [L]YES [¥]NO DRIVE-BY? [_]YES [¥]NO GANG RELATED? [L]YES [¥JNO

HATE/BIAS RELATIONSHIP: —[¥](88) None [_]YES, SEE BELOW
RACIAL (Anti-) RELIGIOUS (Anti-) ETHNICITY / NATIONAL ORIGIN (Anti-) SEXUAL (Anti-)
[J(11) White [1(21) Jewish (1(32) Hispanic [](41) Male Homosexual (Gay)
[J (12) Black an Catholic [](33) Other Ethnicity (_] (42) Female Homosexual (Lesbian)
(13) American Indian / (23) Protestant s {_]43) Homosexual (Gay and Lesbian)
CT alaskan Native {_] (24) Islamic (Muslim) DURABILITY (Am) [_](44) Heterosexual
[_](14) Asian / Pacific Islander [_] (25) Other Religion (](51) Physical Disability [_](45) Bisexual
(-](15) Multi-Racial Group = Multi-Religious Group (](52) Mental Disability
(27) Atheist/Agnostic

Page 5 of 5


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 907.3 for supervision issues observed during the review.

raw_content:
521 Visit Compliance Report

ARKANSAS
) DEPARTMENT OF

> HUMAN
~a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 6/27/2023

Home Visit Date: 6/27/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulation Number: 9. 907. 3

Regulation Description: Staff/child ratio shall be at least 1:6 during waking hours and 1:8 during sleeping hours.

Findings Description: A client was laying down in her bed in Hall B, Room 2218. No staff were present on Hall B.

Action Due Date: 6/27/2023

Action Due Description: Staff immediately notified that client needed staff supervision.

Comply Date:

Sub Regulation Description:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Page 1 of 3

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted. Census: 31.

2 Day Rooms observed. Staff/client ratios: 4:17 and 2:9. Milieu observed staff/client ratio: 1:2.

Halls A, B, C and D observed to be clean, safe and in good repair. Bathrooms were clean with functioning
sinks, toilets and showers. One bathroom was closed due to having a clogged toilet and staff report that
maintenance had been notified. The bathroom/client ratio was still within licensing limits. Hall B, Room
2218, one client was laying down in her bed. No staff were present on the Hall B. Shannon Rouse
immediately notified staff who reported that the client was ill and was being checked on every 15 minutes.
Staff were advised that client needed to be supervised within ratio. Client was immediately moved from the
bedroom to the dayroom for direct staff supervision. Facility cited 907.3: Staff to child ratio shall be at least
one to six (1:6) during waking hours and one to eight (1:8) during sleeping hours.

Cafeteria and Gym observed to be clean, safe and in good repair. Two fire extinguishers observed in the
kitchen which was clean and sanitary.

MAR checked for:

All initialed and up to date.

Provider Comments:

Staff was notified and client was moved from unit to dayroom in order to come into compliance. Agency will do an
in-service to address ratio ensuring staff is present anytime a client is on sick rule.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 6/27/2023

Provider Signature : Date: 6/27/2023

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident eloped from the facility by grabbing a staff member’s keys and scanning herself off the unit. A staff member followed the resident and stayed with her until police arrived to bring her back to the facility.

raw_content:
Maltreatment Narrative:
Licensing Narrative: Facility visited 5/26/23 in response to incident 5/25/23 in which
client eloped from UMCH. Video reviewed from incident which starts in the dayroom,
staff/client ratio: 1:1. was on unit restriction from a prior incident. manages to take
a staff?s badge/facility access device, from her. Staff attempt to follow as she exits the
dayroom with the badge. Video reviewed of hallway which shows client walk down the
hall and exit a door to outside, but not off facility grounds. Another staff member who was
in this hallway attempted to physically block from exiting the facility but was
unsuccessful. Video reviewed from outside of the facility yet still on facility grounds. is
seen exiting the door and walking around the parking lot and eventually out of sight, the
one staff member attempting to follow . A few minutes later 4 additional staff are seen
joining the one staff member. By this time is out of camera view and reportedly off
facility grounds. eloped from UMCH around 3PM and was returned to the facility
around 4PM. A teacher leaving UMCH saw off facility grounds and called the police.
Police returned to the facility around 4PM.


summary: Officers were enroute to this call when they observed a female matching the description given. Officers transported the female and an employee of the facility to the facility.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 5/25/2023 4:41 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2023-058473 2X41 05/25/2023 15:08:00 MISPER

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

5/25/2023 3:08:33 PM

2002 S FILLMORE ST

OFFENSE

NON POLICE INCIDENT

OFFICERS WERE ENROUTE TO THIS CALL WHEN OFFICERS OBSERVED A B/F MATCHING THE DESCRIPTION GIVEN

AT 22ND & FAIR PARK. OFFICERS TRANSPORTED THE B/F AND A EMPLOYEE OF THE ADDRESS TO 2002 S. FILLMORE
ST.

MVR/BWC IN USE.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
05/25/2023 21:40:07 | BREONNA JOHNSON - BREONNA JOHNSON - i MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: Officers responded to the facility and made contact with a staff member who advised that a juvenile ran away from the facility. The staff member provided a photo of the resident to officers.

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Report Contains Juvenile Information
INCIDENT NUMBER 2023-058583 JUVENILE INFORMATION Report generated: 6/18/2023 5:30 PM
Redact Before Release
NARRATIVE
OFFICERS RESPONDED TO THE LOCATION AND MADE CONTACT WITH MS. WHITAKER WHO ADVISED JUV #1 RAN
AWAY FROM THE LOCATION. MS. WHITAKER STATED JUV #1 WAS INSIDE WATCHING TV AND WHEN SHE WENT BACK
TO CHECK ON HIM SHE REALIZED HE WAS GONE. MS. WHITAKER STATED JUV #1 HAS A HISTORY OF RUNNING
AWAY AND WAS LOCATED APPROXIMATELY TWO HOURS AWAY THE LAST TIME. MS. WHITAKER PROVIDED A PHOTO
OF JUV #1 FROM JUST BEFORE HE LEFT. OFFICERS ATTACHED THE PHOTOGRAPH WITH THE NCIC FORM.
OFFICERS ADVISED MS. WHITAKER TO CONTACT POLICE IF SHE OBTAINED FURTHER INFORMATION REGARDING
THE INCIDENT.
*******SUPPLEMENTAL INFORMATION*******
SUBJECT 2 ENTERED INTO ACIC/NCIC AS MISSING 05/25/2023 L PLUMMER Confidential Info
***SUPPLEMENTAL INFORMATION S.BROWN Confidential Info 6/18/23***
PER DETECTIVE BOYD D802 THIS SUBJECT-2 WAS CLEARED FROM ACIC/NCIC.
Page 4 of 5


summary: A resident grabbed a bottle of cleaning chemicals off a cart and drank some of the liquid. The resident was transported to Arkansas Children’s Hospital for evaluation.

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Maltreatment Narrative:
Licensing Narrative: Client in the dayroom, she asked to take a self
time-out after earning correctives for throwing a milk to another client. She went into the
hallway, instead of going to the designated area staff assigned and sat in front of the
entrance door. The housekeeping staff was inside of the exam room cleaning, housekeeping
open the exam room door to exit the room. One housekeeper was mopping the floor and the
other housekeeper stepped in the hallway with the cart waiting for the other worker to finish
mopping. stands up, and walked over to the cart grabbing a bottle with cleaning
chemicals off the cart. The housekeeper was trying to prevent from grabbing items
off the cart, but was able to grab a bottle. Mr. Casey (staff) was present in the
hallway at the time of the incident and tried to retrieve the bottle but was unable to get the
bottle out of hand. unscrewed the lid off the bottle and drank some of the
liquid. Ms. Delores (staff) was walking in the hallway when the incident was occurring and
retrieved the bottle out of 's hand. Nurse Stephanie was notified to come assess the
client. was transported to Arkansas Children's Hospital by MEMs around 8:15 a.m.
returned from the hospital around 10:35 a.m., did not sustain any injuries
from ingesting the chemical. Client was placed on line of sight 24/7, finger foods, no sharps
and no sporks. Facility visited 5/26/23 and video reviewed of incident 5/24/23 in which
client swallowed unknown substance from a maintenance/cleaning cart. Clients
viewed in day area eating, staff/client ratio: 5:18. Client is seen being directed to the
hallway for a time out from an incident earlier in the day. sits by a door, calm and not
saying anything. Maintenance/Cleaning is seen entering the hall is sitting on.
jumps up and grabs a cleaning bottle off the cleaning cart. Cleaning staff is seen
unsuccessfully trying to retain the cleaning bottle. quickly turns up the cleaning bottle
as if to drink it. One staff already in the hall and additional staff all immediately obtain the
cleaning bottle from . A few minutes later a nurse assesses and is seen reading the
ingredients on the cleaning bottle. The nurse is heard saying to send out for further
assessment. Per facility report, sustained no injuries from this incident. Facility
protocol is that if a client is acting out, that maintenance does not clean in that area at that
time. Client was not acting out. was sitting calmly on the floor and gave no
warning before grabbing cleaning bottle. Staff immediately addressed the situation and
obtained the bottle from . was assessed by the nurse and sent to the hospital for
further medical assessment.


summary: Officers responded to the facility for a missing person report. Officers circulated the area and observed the juvenile at a nearby store. The juvenile refused to go into police custody and advised he would return home at 2300 hours.

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Report Contains Juvenile Information
INCIDENT NUMBER 2023-056122 JUVENILE INFORMATION Report generated: 6/12/2023 9:04 AM
Redact Before Release
NARRATIVE
OFFICERS RESPONDED TO THE LISTED ADDRESS IN REFERENCE TO A MISSING PERSON REPORT. DASHA
SANDERS ADVISED JUVENILE 1 LEFT THE RESIDENCE AT 2030 HOURS WEARING GREY HOODIE, BLUE JEANS AND
BLUUE AND WHITE SHOES. OFFICERS CIRCULATED THE ARE AND OBSERVED JUVENILE 1 AT ADAM AND EVE
LINGERIE STORE. JUVENILE 1 REFUSED TO GO INTO POLICE CUSTODY AND ADVISED HE WILL RETURN HOME AT
2300 HOURS. OFFICERS DID NOT OBSERVE JUVENILE 1 TO BE IN DISTRESS AND LEFT THE SCENE PER L33. A
BROADCAST WAS MADE AND A NCIC SUPPLEMENT FORM WAS COMPLETED. BWC/MVR IN USE.
***ADDITIONAL INFORMATION***
SUBJECT 1 WAS ENTERED INTO ALL SYSTEMS AS MISSING. T.FISHER Confidential Info 05/20/2023 0138 HOURS.
***ADDITIONAL INFORMATION*** B HARRIS Confidential Info COMM 05/27/2023 AT 1819
SUBJECT 2 HAS BEEN REMOVED FROM ALL SYSTEMS AS A RUNAWAY.
Page 4 of 5


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. No deficiencies cited.

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ARKANSAS
DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 5/4/2023

Home Visit Date: 5/5/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

PM Buildings & Grounds conducted from 5:00PM-6:30PM. Census: 29. Nurse Adrianna Lockhart escorted
licensing.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Cafeteria observed staff/client ratio: 3:17.
Day room observed staff/client ratio: 1:4

Foyer ratio observed 2:7.

Girl's Halls A and B bedroom areas observed to be furnished, safe, clean and in good repair. Bathroom
observed to be clean and sanitary with functioning sinks, showers and toilets. Client rights posted at nurse's
station window. Fire extinguishers observed and emergency evacuation plans visible and posted.

MAR checked for:

All initialed and up to date. PM meds has just been distributed and were initialed.

Provider Comments:

CCL Staff Signature :

van
V7]
io

a

i

Provider Signature :

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Date: 6/6/2023

Date: 6/6/2023

Page 2 of 2


summary: A resident reported that a staff member threatened him and shoved him hard. Licensing provided the facility technical assistance for 905.4.g as a result of this incident.

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Licensing Narrative: Licensing received maltreatment complaint # as follows: A/v
is , lives with mom , dad and A/O
is staff person at Methodist Children?s home unknown last name. stated
that today 4/23 and him got into an argument and said, ?we will take this
outside? and stated that he said, ?We can fight right now?. said
then threatened him and shoved him hard. There are no markings or bruising.
stated that is always bullying him and making threats (unknown what
type of threats). Email sent to secondary investigator Alexia Hamilton 4/25/23 requesting
permission to contact client after his return from acute. Facility visited 4/25/23 and video
reviewed of entire incident. Client is seen throughout video threatening staff, throwing
food at staff and at one point throwing a pen/pencil at staff. is seen attempting to hit
staff in the head but misses. Staff , and are all seen
throughout this video. No staff is seen or heard using physically threatening behavior. No
restraint is used during this incident. Staff do extend hands, arms as to deflect physical
advances by Staff is heard using the term "gay" when a group of boys
hug at the end of the video. Staff does not present to use this in a lewd, obscene or offensive
way. This does not follow the Teaching Family Model as set forth by UMCH. Staff
will be retrained on Tantrum Management. Received email 5/22/23 that
maltreatment complaint was unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Sharra Singleton-Litzsey
Person In Charge:
Record Visit Date: 4/24/2023
Home Visit Date: 4/24/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 9. 905. 4 .g
Regulation Description: The following actions shall not be used, including as discipline:
Findings Description: Video footage viewed, at no time did A/O mishandle A/V.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Program Manager Litzsey viewed video footage of the incident. Video footage showed clients eating
breakfast. There were 2 staff present with the clients as they ate breakfast. A/V can be seen in getting up in
A/O's face/ personal space and evening touching the A/O. A/V can be seen going up to other clients trying to
get their food. Staff redirect A/V and he eventually sits down. As the video goes on, the clients move across
the hall to dayroom area with 2 staff. Clients are running around and eventually get into the pantry area take
out snacks and pass them out. A/V and A/O have a struggle outside of the view of the camera in a corner by
the day room. Clients can be seen running up and down the hall with staff present. A third staff comes and
attempts to calm the clients down. A/V can be seen attempting to push past staff 3, A/O comes out and tries to
help. A/V pushes A/O, A/O raises his arm to protect himself (never in a motion to hit A/V).
Provider Comments:
CCL Staff Signature : Date: 6/6/2023
Provider Signature : Date: 6/6/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Officers stood by for medical.

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LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

INCIDENT Report generated: 4/23/2023 1:39 PM

INCIDENT NUMBER UNIT ASSIGNED | CALL DATE CALL TIME TYPE OF CALL
2023-045264 1X54 04/23/2023 11:10:00 ASTMED

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME) DISTRICT

4/23/2023 11:10:06 AM 2002 S FILLMORE ST -

OFFENSE

NON POLICE INCIDENT

OFFICERS STOOD BY FOR MEDICAL. NO FURTHER TO REPORT

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR a MVR i
04/23/2023 18:37:03 | CHRISTOPHER FLOWERS {EN »= | CHRISTOPHER FLOWERS ¥IMVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page | of |


summary: Licensing visited the facility to review children’s records. No deficiencies cited.

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521 Visit Compliance Report

ARKANSAS
) DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 4/21/2023

Home Visit Date: 4/21/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Record Review conducted for clients:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Page 1 of 2

All items per minimum licensing standards accounted for.

Provider Comments:

CCL Staff Signature :

Provider Signature :

NPD

In | ae

VU

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Date: 6/6/2023

Date: 6/6/2023

Page 2 of 2


summary: Licensing visited the facility to review children’s records. The facility was cited 902.13 for missing records in a resident’s file.

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ARKANSAS
DEPARTMENT OF

> HUMAN
=a! SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 4/14/2023

Home Visit Date: 4/14/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulation Number: 9. 902. 13

Regulation Description: The facility shall obtain copies of legal documents within thirty (30) days of admission, or
shall document their attempts to obtain the documents. The legal documents shall include, but not be limited to,
birth certificates, social security cards and court orders.

Findings Description: Client Bic not have a copy of a Social Security Card nor was there documentation of a
request for one.

Action Due Date: 5/12/2023

Action Due Description: Case Management note was provided to licensing that case worker had contacted
client's parent to request a Social Security Care.

Comply Date: 4/21/2023

Sub Regulation Description:

Regulations Needing Technical Assistance:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Children's Records Review completed for:

Client was missing a Social Security Card. No documentation of a request for a Social Security Card could

be located. Facility cited 902.13.

Provider Comments:

CCL Staff Signature :

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Date: 6/6/2023

Date: 6/6/2023

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