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

raw_content: The service plan for a youth in care discussion the supervision for the first 30 days of placement. However, the plan does not document the supervision requirements after 30 days.

Correction Narrative: The operation updated the child's service plan to reflect current supervision requirements.


state: TX

facility_name: Journey to Dream - Kyle's Place

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

raw_content: A staff member was released on October 3, 2024, and is still active as of November 6, 2024.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: The staff member is now inactivated. The operation has implemented an exit checklist to complete when staff are no longer employed with the operation. Staff were retrained on how to complete the exit checklist.


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

raw_content: Children were not properly supervised which allowed for an altercation between two children to occur.

Standard Risk Level: High


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

raw_content: A child's service plan was not followed when a child was unsupervised which led to an altercation.

Standard Risk Level: Medium Low

Correction Narrative: RCCR Inspector completed an unannounced follow-up inspection related to inspection 3998143.


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

raw_content: One of the twelve beds inspected did not have a mattress cover. Staff corrected the deficiency at inspection.

Category: Physical Site

Corrected at Inspection: Yes


summary: 748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record

raw_content: Two of two child's files that were reviewed did not contain medication logs for the past months.

Category: Medication

Correction Narrative: The operation is storing medication logs electronically, except for the current month, which is in the child's file. All records are secured in an electronic format and will be provided immediately to licensing upon request.


summary: 748.453(a)(6) - Unauthorized AbsenceAnnual summary log must include if LE was contacted, include name of LE agency & number of police report, if applicable

raw_content: The operation's unauthorized absence log was  incomplete. The log was missing the age of the child, gender of the child, date of admission, when the child returned, which caregiver was responsible for the child at the time of the unauthorized absence, the intake number and if law enforcement was contacted.

Category: Reports and Record Keeping

Correction Narrative: All staff completed a training for Unauthorized Absence Log documentation on February 14, 2024. Staff were retrained to correctly document the Unauthorized Absence Log with the information outlined in Minimum Standards. Inspector reviewed the sign-in sheet with all staff signatures to verify this training was completed. The operation corrected the current Unauthorized Absence Log that Inspector reviewed for compliance.


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

raw_content: A staff member uses yelling as a form of discipline with the children in care.

Standard Risk Level: Medium High


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: Administrator was made aware of an unforeseen circumstance and failed to implement a plan for proper supervision.

Correction Narrative: A phone call with the Administrator of the operation was held to discuss compliance. It was stated that an all-staff meeting was held to review the general responsibility and duties of each staff member while in ratio.


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

raw_content: Operation staff failed to use prudent judgement when children in care were denied access to the facility.

Correction Narrative: A phone call with the Administrator of the operation was held to discuss compliance. It was stated that an all-staff meeting was held to review the general responsibility and duties of each staff member while in ratio. The minimum standards and definitions of normalcy and prudent judgment were discussed during the meeting so there is a clearing understand for each staff member.


raw_content: A staff member leaned in with her body and forcefully spoke to a child after an altercation.

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

Correction Narrative: An unannounced inspection was conducted at the operation. A discussion with the Administrator took place; the Administrator stated that there was a meeting with the Ombudsman representative to discuss Child's Rights, I was informed that they the children in care have access to 2 cell phones and 1 landline (which were observed) to make phone calls anytime they want. It was also stated that during the meeting yelling was discussed and they talked about the difference between yelling at a child and being stern/directing the room with a heightened voice. Staff were interviewed to confirm the meeting and discussions.


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

raw_content: The unauthorized absence log was not available for review when requested during the inspection.

Correction Narrative: An email was received from the administrator with an unauthorized absence log. The log has a space for all required documentation requirements per minimum standards. The administrator reviewed the procedure with staff during a staff meeting conducted on 6/9/22 to utilize the log per minimum standard requirements.


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

raw_content: While reviewing the children files one of the records did not have a signature for the PLSP on the admission assessment.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative: An email was received from the administrator with details of the new procedure for attaining signatures for all required parties; Each admission is to be processed through a formatted and standardized admission packet with all required documents, with each document reviewed with the youth and their caseworker at the time of admission. All parties will be required to sign documents at the time of admission. The Residential Supervisor will audit all admissions documents to ensure that all documents are completed and signed within 24 hours of the youth's admission into the program.


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

raw_content: As a form of discipline, operation staff pulled a child's mattress to the floor while the child was still on it.

Correction Narrative:
An email was received from the administrator of the operation. She stated that the all staff members have been re trained on appropriate discipline techniques as well as managing difficult behavior methods (SAMA and Love & Logic) new courses have been added as well (How to help children with challenging behaviors, High-Risk Behaviors in Young People and Staying the Course with addressing Behaviors
Positive Behavior Intervention and Support). The caregivers directly involved in the incident were counseled about how to better address behavioral challenges. An inspection was completed on 2-1-22 to ensure compliance, there were no concerns observed.


raw_content: The operation did not have an unauthorized absence annual summary log.

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

Correction Narrative: An email was received from the administrator of the operation. They provided a log that shows all of the required information for the unauthorized absences. The operation will use this log moving forward.


raw_content: A child was placed in isolation with no contact allowed with other residents as a form of punishment.

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

Correction Narrative:
An extension was granted due AR request.

An inspection was conducted at the operation. A walk through of the area where the child was isolated was completed. There was a discussion with the Case Manager that all staff have been informed of proper searches of a child in care, upper management will conduct the search, there will be 2 staff present and there will be a male staff member available if a boy needs to be searched (because all upper management are female). All staff have been advised that they are not to seclude a child and should use other methods such as a search if the need arises or a heightened supervision of 1 on 1.


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

raw_content: A child with a history of substance abuse was not properly supervised when allowed to leave the operation to attend work. This provided the child with an opportunity to purchase a firearm and engage in drug use.

Correction Narrative:
An extension was granted due AR request.

An inspection was conducted at the operation. There was a discussion with the Case Manager that all staff have been informed of any child with a high risk behavior history has to be checked on hourly with either a phone call, drive there or text a picture and they also receive all work schedules.


facility_name: Valley Haven, Inc.

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

raw_content: There were no documention availabe for review indicating efforts in contacting references.

Category: Personnel

Correction Narrative: Program Director will now perform a final review and sign-off on all new hire documentation to verify that all screening is complete prior to their start date. Completed referenced were subimtted via email.


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: Dosage was not administered to child in care as prescribed.

Correction Narrative: Email was sent to employees regarding new implemented policies for medicaiton administration and medication logs. In additoin, case managers and program director compelte weekly audits to ensure medicaiton logs are compelted timely with all requirements.


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: Caregiver was unaware of child's special needs in regard to vaccine requirements.

Correction Narrative:
As of March 3, 2026, the case management department staff have been instructed to check the childrens electronic file to ensure all initial and ongoing medical needs are met during their scheduled visit.

On March 3, 2026 a meeting will take place with all members of the case management department to discuss the need to check childrens electronic file on Extended Reach to ensure all initial and ongoing medical needs are met during their scheduled medical visit.

Immediate correction and preventive training will be completed by March 3, 2026.

Full compliance has been achieved. Ongoing oversight will be provided by the Licensed Child Care Administrator and Program Director, who will ensure that all caregivers are aware of children's immediate and ongoing needs.


summary: 748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity

raw_content: A staff member allowed a 9 year old girl to shave her legs


summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: During the course of an investigation, a supervisor stated they did not know if the child in care he was responsible for had any sexual abuse history.

Correction Narrative:
Email received by Administrator:

Resolution of the Issue:
On 2/21/2022, the Director of Compliance and House Manager, met with Valley Haven Supervisors to discuss the deficiency received and the importance of continued awareness of the level of care for each child residing at Valley Haven. Mr. Reyes also reminded the Supervisors that when they sign the required forms at the time of placement it is crucial to ensure that the caregivers understand and are aware of each child's history. The supervisors informed Mr. Reyes that they understood.
Preventative Measures Taken to Minimize Future Reoccurring Citations/Deficiency:
Upon every placement at Valley Haven, DFPS is required to provide Valley Haven with a completed Placement Summary Form and its Attachment A- Child Sexual History Report. The report provides any history of sexual victimization or sexual aggression for each child placed at Valley Haven. When a history of sexual aggression, behaviors, or victimization is identified after placement, DFPS provides an updated Attachment A to Valley Haven to ensure that Administration addresses the child's safety, any therapeutic needs, and other children's safety.
At time of placement and when the Attachment A is updated, the child's placement administrator, receiving intake staff (as applicable), and the child's case manager are required to sign the Placement Summary Form and its Attachment A (or an updated one) and return it to the child's DFPS caseworker. If any of these required signatories are not present at the time of placement, the child's placement administrator, or their designee in their absence, ensures all required signatories sign and return these documents to the child's DFPS caseworker within three business days.
At the time of placement, and when the Attachment A is updated, each child's placement administrator or designee is required to inform all supervisors/caregivers if a child has a history of sexual aggression, behaviors, or victimization as provided for by DFPS in Attachment A. As proof of this notification, the
placement administrator or designee obtains each supervisors/caregivers signature on the certification form attached to the Placement Summary Form, Attachment A. By signing the certification statement, the signatories acknowledge that they have read the DFPS Placement Summary Form, Child Sexual History
Report (Attachment A), and are aware of the child/youth's history of sexual victimization or sexual aggression. The signatories also agree they have or will do the following:
 Discussed its implications with their employer.
 Understands the importance of applying strategies to the direct care of the child/youth to ensure the safety, health, and well-being of children/youth in care.
 Understands the confidential nature of this information.
 Agrees not to disclose such information except for a necessary purpose authorized under the
DFPS Contract or to protect the safety, health, and well-being of children/youth.
The placement administrator maintains copies of the certification form for each child at Valley Haven and provides such to Valley Havens Residential Contract Manager and DFPS quarterly and upon request.


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

raw_content: During the course of the investigation, interviews indicated that staff were restraining children in care.

Correction Narrative:
Follow up inspection was completed on 12/21, random children were interviewed regarding discipline.

The LCCA met with the
supervisors and caregivers at
Valley Haven regarding the
EBI policies at Valley Haven
and reminded them that EBI is never allowed to be used on a child as a means to get a child
to comply.
To prevent any future reoccurrences of this
deficiency, Valley Haven will continue to
train all Direct Care Staff in EBI and follow
the training schedule that is already in place
for each employee that provides Direct
Care. EBI training is completed every 3
months as a refresher for the employees to
provide methods of appropriate discipline,
multiple tools for redirection and positive
reinforcement for misbehavior. Valley
Haven only allows short personal restraints
in the event a child is in immediate danger
to him or her self or another child in care.
All staff is trained in TBRI and utilizes de-escalation techniques to prevent any
restraints and does very well at utilizing the
tools provided in their trainings.


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

raw_content: During the course of the investigation, interviews indicated that restraints were conducted and no documentation was noted in the childrens files.

Correction Narrative:
Follow up inspection was completed on 12/21, random children were interviewed regarding discipline.

The LCCA has met with all supervisors and caregivers at Valley Haven regarding the policies in place that require all incidents to be documented no later than 24 hours in the
children's file.
To prevent a reoccurrence of this
deficiency, Valley Haven LCCA went over
the documentation requirements for any
incidents that occur at Valley Haven. Valley
Haven caregivers & supervisors are already
required to document any incident with a
child, even minor incidents that include
verbal arguments/ disagreements that a
child may have. The staff was reminded that
there has been no change and the
documentation is always required.


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

raw_content: A child in care did not have any documentation of immunizations.

Category: Child Care

Correction Narrative:
Email received from administration

Corrections:
The LCCA has submitted a variance request to RCCL asking for an extension that will allow Valley Haven's Case Management team more time to work with the child's Pediatrician, School and CPS Worker on receiving the current Immunization Record.
As of right now, the Immunization Record provided by the child's Pediatrician that is on file states no record and there is documented weekly correspondence between the Pediatricians office and Valley Haven.
The correspondence and request for records will continue weekly or until the minimum standard is met.
If the immunization record is not found by the extension deadline (10/28/21), Valley Haven will request an immunization schedule or an exemption from the child's Pediatrician to become compliant with the Minimum Standards.
Preventions of Reoccurring Deficiency:
To prevent a reoccurrence of this deficiency, Valley Haven will submit a variance request for an extension that will provide more time to be able to receive the most current immunization records for any children that do not have an updated Immunization Record on file.
In the event Valley Haven comes across another issue of no records being found for a child and the pediatrician does not recommend an immunization schedule (because he feels there is an error in the system), Valley Haven will have an exemption on file from the doctors office that complies with the Minimum Standards.


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

raw_content: Operation active records were not available for review at the time of inspection.

Correction Narrative: The standard was found to be compliant


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

raw_content: A minor was in the bathroom for a long period of time during which the minor self - harmed and Staff did not provide proper intervention.

Correction Narrative:
Follow up completed on 3/15/22
The administrator submitted an request for AR via email on 07/23/2021 @ 1:30 PM.
Email received from administrator:
Resolution of the Issue:
On 3/08/2022, Fernando Reyes, Director of Compliance and House Manager, met with Valley Haven Supervisors to discuss the deficiency received and the importance of ensuring all caregivers provide the level of supervision necessary to ensure each child's safety and well being. The supervisors informed Mr. Reyes that they understood.
Preventative Measures Taken to Minimize Future Reoccurring Citations/Deficiency:
Fernando Reyes discussed appropriate timeframes for children taking showers and reminded the Supervisors and Caregivers that even though teenagers take longer times in the showers, they must frequently check on them to ensure they are safe and at the same time respect their privacy.
Date and Timeframes for Compliance:
Valley Haven began implementing the preventative measures discussed above on 07/08/2021 and on 03/08/2022. Compliance will continue to be ongoing and will occur for every child placed at Valley Haven.


summary: 748.303(a)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: A child in care involved in an Incident where professional medical attention was given was not reported to Licensing.

Correction Narrative:
Follow-up completed 3/15/22
The administrator submitted an request for AR via email on 07/23/2021 @ 1:30 PM.
Email received from administrator:
Preventative Measures Taken to Minimize Future Reoccurring Citations/Deficiency:
To prevent future reoccurring citations/deficiencies, Kristen Millon will call in a report to licensing no later than 24 hours after the injury/illness if a child receives treatment by a medical professional at the hospital due to a psychiatric evaluation.
Date and Timeframes for Compliance:
Valley Haven began implementing the preventative measures discussed above on 03/08/2022. Compliance will continue to be ongoing and will occur for every child placed at Valley Haven.


facility_name: ACH Child and Family Services

summary: 748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean

raw_content: The sink in the classroom near unit A was found to have rust while the sink in the classroom near unit B was found to have a broken handle.

Correction Narrative: The sinks in the classroom were observed to be compliant.


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

raw_content:
One of the bathrooms in unit B was found to have water on the floor and was not draining the water properly in addition to having peeling paint below the mirror on the sink and on the toilet. Two other bathrooms in unit B were found to have peeling paint on the soap dispensers and on the toilets and in one of these, there was dirty water observed on the railing under the sink.

Three of the bathrooms in unit A were found to have peeling paint on the soap dispensers, on the toilets and below the mirrors above the sink.

Correction Narrative: The bathrooms are draining properly and there was no peeling paint observed on the soap dispensers, the mirrors and on the toilets. In addition, the railings were observed to be clean and properly drained.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: One of the children underwent surgery on 1/5/26 and this was not reported into the statewide hotline.

Correction Narrative: A follow-up inspection was conducted and 1 child and 2 staff members were interviewed.


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

raw_content: It was determined that caregivers were displaying inappropriate behaviors, caregivers were having inappropriate conversations in front of the children and were showing favoritism towards some children.


summary: 748.3305(b) - Physical Site-Each porch or deck that has over an 18-inch drop must have a well-secured railing

raw_content: The unit deck did not have a railing around the side which had a drop off of more than 18 inches.

Correction Narrative: Railings were added on both sides of the unit decks.


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

raw_content: The people list was reviewed, and background checks for two employees were inactivated a few months after they were no longer associated with the operation. In addition, the administrator did not have their background check inactivated within seven days of leaving the operation.

Correction Narrative: RCCR Inspector received an email from the administrator stating that the operation was conducting an audit of their background check portal to ensure all records are accurate and up to date. The administrator stated that they would add a weekly team checklist reminder to review the portals to ensure compliance.


summary: 748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times

raw_content: The operation did not have the notice of keeping children safe at the operation.

Category: Organization and Administration

Correction Narrative: The operation posted the notice of keeping children safe.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content: Leadership failed to notify licensing of a change in controlling persons within the two day time frame.

Correction Narrative: RCCR Inspector received an email from the Chief Compliance Officer who was currently the administrator stating that they would be maintaining the list of all controlling persons and assigned administrators and would ensure that future notifications are made within the required timeframe.


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 out of two child medication logs reviewed did not have a record of administration of the medication as prescribed.

Correction Narrative: A weekly medication audit is conducted to ensure compliance.


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

raw_content: Two out of three child medication logs reviewed did not have the accurate count for two medications they were taking.

Correction Narrative: The medication count was found to be accurate.


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

raw_content: During the walkthrough, 1 out of 3 freezers were observed to be at 22 degrees Fahrenheit.

Correction Narrative: The freezer thermometer was observed to be at -6 degrees Farenheit.


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

raw_content: During the Investigaton it was discovered that a staff member was unfamiliar with the agency's operational policies.

Correction Narrative:
RCCR Inspector made phone contact with the administrator to request for compliance documents, and he stated that the staff were retrained on how to handle fights/confrontations on 9/3/25 and he thought that he had already sent me the compliance documents via email, but I informed him that he had not. Compliance documents were sent to me after the phone call, and the documents were reviewed.

On 9/3/25, the staff members were retrained on client safety protocols which included:
1.  Having a supervisor scheduled in each 2nd shift during the duration of the safety plan.
2. Staff members will insert themselves between residents who are engaged in a verbal escalation before it becomes physical.
3. If a physical confrontation is about to occur, staff members will utilize EBI techniques, separate the residents and move other residents out of the area.
4. Staff will intervene when physical altercations occur and immediately separate the residents using MAB and UKERU.
5. Staff members will reach out to other staff members using walkie talkies or other means to prevent escalations.

17 signatures of staff members were also provided. The document can be found in the document library.


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

raw_content: It was observed that staff implemented EBI techniques in the presence of several children without adequately protecting the privacy of the child involved.


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

raw_content: It was noted that staff members did not attempt to deescalate the behavior of a child before performing a restraint on them.


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

raw_content: Staff members were observed not intervening when children in care were escalated.

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


raw_content: The thermometer was observed to be at a temperature of twenty degrees fahrenheit.

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

Correction Narrative: The thermometer was observed to be at a temperature of negative four degrees fahrenheit.


raw_content: A staff member did not demonstrate prudent judgement when he used his foot and body to block one of the residents in their room and dragged the child while they were on their mattress.


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

raw_content: A staff member secluded a child in their room by blocking the door with their foot and body.


summary: 748.2451(a)(4)(A) - Seclusion-Only for child with ED or PDD when 25+ children with ED or PDD or >30% of children with ED or PDD; not allowed for child in therapeutic camp

raw_content: A child was in their bedroom and a staff member blocked the door by using their foot, preventing the child from opening or leaving the bedroom.


raw_content: The thermometer was observed to be at a temperature of ten degrees fahrenheit.


raw_content: During the walkthough, 1 out 3 freezers were observed to be at 20 degrees Fahrenheit.


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

raw_content: A staff member scrolled through a cell phone during an altercation. While the staff member viewed their phone, children in care engaged in a verbal altercation. A child in care was left in the room for 1 minute. While alone and in the hearing of staff members, the child expressed suicidal ideations.

Correction Narrative: RCCR Inspector conducted an unannounced follow up visit on 4/15/25 and the inspection number is 4052241. Two children and one staff were interviewed regarding supervision and cell phone usage. A phone usage protocol memo containing staff signatures was provided and it can be found in the document library.


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

raw_content: A bathroom in unit B was found to have water on the floor and was not draining the water properly. The shower head was also not in proper working condition.


raw_content: A video was reviewed showing two caregivers not intervening when a child was harming themself.

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

Correction Narrative: The operation came into compliance by making sure no kids get access to self harming items and a safety plan was implemented by the operation to reduce self-harming behaviors of a child in care .


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 the preliminary service plans reviewed did not have a signature from the treatment director or PLSP.

Correction Narrative: RCCR Inspector conducted an unannounced follow up visit on 11/14/2024 and the inspection number is 4029799. The child's file was reviewed, and the preliminary service plan was updated to reflect the signature from the clinical director.


raw_content: A child in care did not recieve their morning medications. An administrative penalty in the amount of 100% of the daily maximum, per HRC 42.078(a-2) will be recommended as a result of this citation.

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


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: Loose medication was observed in the medication drawer.


summary: 748.2101(5) - Medication Storage - keep medication storage area(s) clean and orderly

raw_content: A child's medication was observed to be in another child's drawer. This was corrected at the inspection when staff moved the medication to the correct child's drawer.


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

raw_content: The service plan indicates that the child should be learning how to cook healthy meals for themselves.


summary: 748.1699(c) - Nutrition-if meal or snack not appropriate to meet a child's individual needs, then must offer an appropriate nutritional substitute

raw_content: A child that was diagnoses with high cholesterol is not being offered a nutritional substitute for meals and snacks.


summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: The menu did not list the snacks that are provided to the children in care.


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

raw_content: One of the two medication's reviewed did not have the updated count on the medicaiton log.

Correction Narrative: The medication logs reviewed were found to be in compliance.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The administrator did not ensure compliance with a safety plan when a staff person who was limited in contact with a child was able to interact with the child.


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

raw_content: It was determined that a caregiver did not create a safe environment for a child in care when failing to adhere to a safety plan causing the child to be triggered.


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

raw_content: A caregiver was found to have threaten to hit and physically harm the child.

Correction Narrative: A caregiver was found to have threatened to hit and physically harm the child.


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

raw_content: A youth care specialist admitted to using profanity towards a child in care.

Correction Narrative: RCCR Inspector conducted an unannounced follow up visit on 5/15/2024 and the inspection number was 4001903. Two children were interviewed about the staff using profanity and there were no concerns. The compliance was also met by the operation whereby they held an interdisciplinary treatment team meeting and ensured that staff had read the communication binder regarding profanity and a copy of the signatures of the employees was provided.


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

raw_content: During the inspection, on Unit B, in one of the bedrooms, the trim in the corner by the bed was detached from the wall and appeared that it could fall.

Correction Narrative: The strip of Formica has been repaired as instructed and a picture of the correction can be found in the document library. The administrator the provided the pictures of the fixed trim.


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: Due to the child's history, the safety plan did not implement a plan to ensure the proper protocol to keep a child safe that has a history of self-harm.

Correction Narrative: Admission procedures were reviewed, and we will continue to identify high risk behaviors in our intake assessment, and we will continue to develop a safety plan for every new resident in our program. We will continue to update resident safety plans to ensure staff are kept up to date on all high-risk behaviors and our current interventions to negate as much of the risk as possible


raw_content: A child was able to obtain a pair of scissors and use to cut their own hair.

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

Correction Narrative: The decision has been made and implemented to remove all scissors from the RTC building other than one pair to be kept in the knife cabinet pictured above.  We have also reorganized the knife cabinet to better account for all our sharps including disposing of all our current cutlery and ordering new cutlery that can be hung in the cabinet for easy auditing.  The scissors are labeled and included in the cabinet.  This cabinet is locked and is also located in a locked pantry, inaccessible to the children residing in our program.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: Child files reviewed, two out of two files were missing the child's religion or religious preference.

Correction Narrative: Religious preferences were added to the two files missing them and will now be documented on all intakes going forward.


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

raw_content: 7 child medication logs were reviewed. Of the 7 logs reviewed, 5 child files documented a medical professional who was not the actual physical listed on the medication label.


summary: 748.705(b)(2) - Reasonable & prudent parent standard-must consider the child's cognitive, social, emotional and physical development level

raw_content: An employee at your operation showed favoritism to one particular child as well as buying inappropriate gifts for this child.

Correction Narrative: Operation indicated that employee is no longer on shift at RTC location and has no contact with any children at the RTC. Employee will meet with the Residential Director regarding his status as an employee and will be required to complete a personal boundary training with the Residential Director before being again given access to the RTC Program or its residents.  This meeting and training will occur prior to any prolonged access to the RTC Program or residents.


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: 1 of the 2 employment files reviewed did not have "none" written on the notarized affidavit concerning incidents involving children as required.

Correction Narrative: Operation provided required updated notarized affidavit


summary: 748.531(b) - Child-care administrator-If acting as administrator for two operations, split full-time schedule per professional staffing plan for each operation

raw_content: The LCCA is the administrator for two operations however a written staffing plan was not completed.

Correction Narrative: Operation provided written plan on 10/12/22. Verified during inspection at operation.


summary: 748.2203(c)(1) - Medication Error-Document the time & date of the error

raw_content: The medication logs for four children do not document the medication error including the time and dates the children were without medications.

Correction Narrative: An inspection was completed at the operation on 11/08/2022 Medication logs were reviewed for both male and female residents and found to be in compliance. Operation treatment director does daily checks of medication log to ensure accuracy


summary: 748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for

raw_content: A child in care service plan indicated that she not to be left alone no more than 15 minutes at a time. The caregiver responsible for supervising a child, left the child alone for over 40 minutes unattended, thinking other caregivers were supervising her.

Correction Narrative:
Operation Response:
Our new lanyard system ensures that every staff member knows exactly which child they are responsible for as they will be literally wearing the name of the children they are supervising around their necks.  As the staff switch up supervision responsibilities, so will the lanyard travel.  For example, a staff member has John Doe's lanyard around their neck along with three other children they are supervising during school hours.  John Doe has an appointment at the dentist so the staff member transporting John Doe will not only take John Doe but also will wear his lanyard during the appointment, ensuring the lanyard passes along with the resident from staff member to staff member.  The Safety Plan on each lanyard will also include how often checks will need to be done when a resident is in their bathroom, in their room or in the sensory room, etc throughout the day.  Our standard supervision includes 15 minute checks during sleeping hours and 10 minute checks during awake hours.


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

raw_content: Management staff did not instruct direct care staff on what was the supervision requirements for a child with known self-harming behaviors.

Correction Narrative:
Operation Response:
The new lanyard system, the supervision requirements will be printed each resident's safety plan and this safety plan along with the child's name will be worn on a lanyard by the staff responsible and will be passed to the next staff responsible be it during a shift change or simply a staff member taking a break and passing supervision responsibilities to another staff member.  Included on the safety plan will be supervision requirements and special instructions for issues such as self harm behaviors or elopement risk, etc.


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

raw_content: Staff responsible for the supervision of a child in care did not  provide the level of supervision indicated on the preliminary service plan.

Correction Narrative:
Operation Response:
We have implemented a Lanyard System that included all staff wearing a lanyard which has the child they are responsible for along with a copy of their safety plan on the lanyard for easy reference. As staff pass a child to another staff member for supervision, the lanyard then is passed to that staff as well.  This ensures every child is always supervised and the staff member responsible for the resident knows who they are responsible for at any given moment.  Most importantly, any service plan information that is in need of a safety plan will be transferred to the lanyard and the staff member responsible for the supervision of the resident will know that information as it will be printed on the lanyard.  In response to the TA given, we will also be documenting/auditing verification that each staff member is following each child's supervision plan in part by assigning staff to children and their associated lanyards at the beginning of each shift and documenting the headcount at the end of each shift ensuring all children are accounted for each shift.  Supervisors will be meeting with each staff member during shift change ensuring they know the supervision plan and that it will be followed throughout the shift.


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 did not use appropriate de-escalation techniques with a youth in care.  The caregiver taunted the child by swinging a mop in the childs direction as well as mopping a beanbag used by the youth.

Correction Narrative: Inspector T. Amie staffed case with Supervisor regarding deficiency. A background check was ran on employee for whom deficiency was issued and it shows that as of 06/29/22 that the employee is inactive and no longer affiliated with operation and presents no risk to children in care.


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: 1 child left the operation on 07/18 and returned on 07/18. The serious incident report does not document a debriefing with the child.

Correction Narrative:
Compliance Plan:
Operation informed that Refresher training on how to properly complete an Incident Report, including how to complete a debriefing with youth upon their return from a runaway incident, will be conducted by the Director of Residential Services-Wichita Campus and/or Clinical Manager  and will be initiated no later than 10/1/21. In addition, prior to approving submitted incident reports, the Director of Residential Services-Wichita Campus and/or RTC Program Manager will require the debriefing section be complete prior to approval and will follow-up with the staff submitting the report to ensure this information is added as appropriate.


summary: 748.303(a)(9)(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: A child in care ran away from the operation on 07/18 and returned on 7/19 and the report was received on 7/23.


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

raw_content: Caretakers at the operation did not provide proper supervision to a child in care allowing for the child to cause a self injury to themselves requiring hospitalization

Correction Narrative: Operation provides specific supervision protocols for residents as needed. The subject of this investigation has been discharged and is no longer at the facility.


summary: 748.3441(i) - Food Preparation-Food packages must be in good condition & protect the integrity of the contents

raw_content: Multiple food packages were open and exposed the food inside.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: Multiple bathrooms were found to not have something available for the children to dry their hands.


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

raw_content: Mulitple refrigerators and freezers did not have thermometers.


raw_content: Oxcarbazepine was missed on 04/13. Sprinterc 28 was missed on 04/13. The reason why the medication was missed was not documented.

Standard Number / Description: 748.2203(c)(1) - Medication Error-Document the time & date of the error


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: The kitchen had 1 bag of chicken and two bags of stir fry defrosting in the sinks.


summary: 748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident

raw_content: Police responded to a call made by the operation to assist with child behaviors on 02/08. The police response/arrests were not reported to Licensing until 02/17.


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

raw_content: A staff member restrained a child to prevent the child from running away.

Correction Narrative: New EBI Policy has been adopted by the operation which is on file on Sharedrive. This policy was adopted in response to other EBI issues the operation had, and has been put into place during the time this investigation was on A/R status


facility_name: The Residence By Infinity Elite II

summary: 748.2101(8) - Medication Storage & Destruction-remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access

raw_content: Medications for two discharged residents was observed stored at the operation.

Correction Narrative: The medication was observed to only have medication for children in care.


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

raw_content: Four psychotropic medications were observed stored single locked.

Correction Narrative: All active medications were observed double locked during my inspection.


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

raw_content: The backyard of the operation was observed to have several nails exposed in two different areas.

Correction Narrative: The backyard fence gate was observed to be replaced and closed securely.


summary: 748.4209(a) - Placement Extension-Child's service planning team must document the reason for the placement extension in the child's record

raw_content: Three placement extensions for a child in care was observed without an applicable reason to keep the child in the emergency placement.

Correction Narrative: Per the Administrator, the child's service planning team continues to documents a detailed, formal reason for every placement extension directly in the child's record before the extension is finalized (keeping in mind that these conversations occur in person and telephonically).


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

raw_content: A child's 30, 60 and 90 day placement extension documentation were observed to be pre-dated and completed at initial placement for placement extensions.

Correction Narrative: Per the Administrator, they have ceased the practice of pre-dating any record; all placement extension documentation is now completed and signed only on the actual date of the service planning meeting to ensure true and accurate records.


raw_content: During the inspection, a staff was seen and heard sleeping while supervising a child in care for at least 10 minutes.

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

Correction Narrative: During my inspection staff were observed actively supervising children in care. Additionally, two out of four children did not report any concerns with the specific staff sleeping.


summary: 745.8311(b) - Waiver/Variance - Comply w/ each condition while in effect

raw_content: The operation did not comply with the conditions of notification of discharge to licensing on multiple variances.

Correction Narrative:
Per the Administrator, she will inform the team when youth are discharged.
10/1- at the HM inspection, variance conditions were reviewed, and Licensing was notified of 2 child discharges as required per the conditions.


raw_content: The childs file reviewed did not include a complete preliminary plan for discharge.

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

Correction Narrative: Per the Administrator, she will continue to ensure that the plans are completed.


summary: 748.363(13) - Personnel records-Include record of training and training hours.

raw_content: Suicide prevention training does not contain how many hours the training was conducted.

Correction Narrative: Per the Administrator, they will maintain complete and current records of all training completed, including total training hours, for every employee in their personnel file. For those that dont have-we will write it in.


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

raw_content: The childs service plan reviewed did not include the child's signature or a explaination of refusal.

Correction Narrative: Per the Administrator, they have reinforced the requirement that every child signs their Initial Service Plan, with immediate documentation of refusal recorded directly in the child's file as necessary.


raw_content:
One employee record did not contain true and accurate information of their date of birth.

A child's admission assessment lacks pertinent details.

The staff list did not accurately reflect active employees.

Correction Narrative: Per the Administrator, she will continue to check maintain accurate and complete records.


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

raw_content: Ice cream was observed expired and chicken was observed with open packaging in the deep freezer. Both food items were disposed of during the inspection.


summary: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

raw_content: Multiple children are utilizing the downstairs bathroom located inside of the recreational area to shower, when their bedroom is upstairs.

Correction Narrative: A physical follow up was conducted and the room was observed to be changed to a bedroom for children to utilize the room and restroom. The children have ample of closet space and do not have to cross another room to shower.


raw_content: The childs service plan reviewed did not indicate the childs participation or signature.

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

Correction Narrative: Per the Administrator, We ensure that every child signs their Initial Service Plan, or if they refuse, the refusal is documented immediately in the child's record by the case manager.


summary: 748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided

raw_content: A written Recreation Plan was not available for review during the inspection.

Category: Recreation Activities

Correction Narrative: The operation's LCCA submitted via email the operation's Corrective Action indicating that the Operation has amended the schedule to show that youth are provided recreation activities beyond expectation.


summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: The provided First Aid Kit did not have a thermometer or waterproof disposable gloves.

Category: Safety and Emergency Practices

Correction Narrative: The operation's LCCA submitted via email the operation's Corrective Action indicating that Operation will continue to maintain appropriate supplies in the 1st aid kit.


summary: 748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available

raw_content: Per the Administrator, Health/Sanitation Inspections are not available in the area that the operation is located, there is no documentation of that determination for review.

Correction Narrative: The operation's LCCA submitted via email the operation's Corrective Action indicating that the operation has health inspection from 2021 that has never left the location and will continue to be available.


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

raw_content: During the inspection, there were no documented Unauthorized Absence Logs for review.

Correction Narrative: The operation's LCCA submitted via email the operation's Corrective Action indicating that the Logs will continue to be available upon request.


summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: The provided Menu did not list all daily meals and snacks provided by the operation. Nor did it list food substitutions, and there were no menus for review for the last 90 days.

Correction Narrative: The operation's LCCA submitted via email the operation's Corrective Action indicating that that the operation has placed menu and snack menus in view for all to view. Was also updated to ensure continued compliance.


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

raw_content: The posted Emergency Evacuation diagram does not include the 2nd floor to the operation, nor does it include the designated location inside operation to take shelter from threatening weather.

Correction Narrative: The operation included the upstairs floor plan on the second level.


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

raw_content: During today's inspection, bedroom three was observed to have still have the window screens to still be damaged along with an additional screen.

Correction Narrative: The bedroom windows have been securely fastened by screwing them in to ensure they remain closed and stable. To further address pest concerns, bug repellent was applied around the window arears to deter insect entry.


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

raw_content: The operation was cited for this standard during the last HM inspection on 4-2-25. During the follow up by inspection at the facility today, it was observed that the damaged couch and cabinet in the restroom has not been repaired or removed to ensure the safety of the children.

Correction Narrative: During the follow up by inspection at the facility today, it was observed that the damaged couch, cabinet in the restroom, and stairs rails have been repaired.


summary: 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

raw_content: The advance 2 weeks notice to the DFPS staff regarding initial service planning meeting was missing in the childs file.

Correction Narrative: The operation provided corrections indicating they have them sign at admission that they have been given the CPOS meeting information. Will continue this and admin will monitor. We weren't out of compliance so there was no correction.


summary: 748.1337(b)(1)(K) - Initial Service Plan-Include names and roles of persons who participated in service plan development

raw_content: One child initial service plan was missing the names of the participants.

Correction Narrative: The operation provided its written correction via email. In its correction, the operation stated that the names were present, and signatures were present where the document requested. The inspector suggested to print the names (there is no area for this) and TRIE, II staff will ensure our spaces have both signature and printed names.


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

raw_content: During the review of a childs file, multiple dates of birth were noticed. The date of birth in the intake form, the binder cover and placement summary says 9 years while the discipline notification form for the child says child is 10 years.

Correction Narrative: The operation provided the following corrections indicating that they will change the data or info that the CW writes on our documentation to reflect what is on their paperwork. All staff can monitor and review. We simply crossed out his info and wrote other age.


raw_content: During the walkthrough of the facility, one of the couch in the living room area was observed not to be in good repair condition. The chair is very uncomfortable and you can feel the spring when you seat on it. One cabinet was also observed to be damaged in the restroom.

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


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

raw_content: During the review of this investigation, it was noted that staff used the date 1-26-25 as the date of incident involving the victim child in an incident report while child was admitted to the facility on 1-28-25 according to the child's 72 hours service plan. Child was not at the facility on 1-26-25.

Correction Narrative: Operation will ensure to keep accurate results


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

raw_content: The freezer in the garage contained food items. There was no thermometer located inside the freezer to obtain a temperature reading.

Correction Narrative: 12/09/2024-The operation's LCAA submitted to licensing staff via email the operation's Corrective Action Plan. The operation's LCCA provided a photograph displaying a freezer thermometer measuring the temperature of the air (appropriate temperature reading) in the deep freezer demonstrating compliance in accordance with Minimum Standards.


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

raw_content: A child received their 72-Hour Health Screening late.

Correction Narrative:
12/24/2024-The operation's LCCA submitted to licensing staff via email the operation's Corrective Action Plan.  The operation's LCCA provided communication indicating the operation will continue to follow policies as related to medical and dental ensuring each child receiving emergency care services receive a health screening or EPSDT examination within 72 hours after admission as implemented by the LCCA.

Additionally, the LCCA communicated the youth was taken to ER prior to 3-Day Medical Exam as well as the operation has requested documentation but has been unsuccessful in obtaining documentation. The LCCA reported the youth was taken to subsequent medical appointments as well.


summary: 748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.

raw_content: A child exhibited warning signs of suicide, and no documentation of a risk assessment was conducted.

Correction Narrative:
12/18/2024-The operation's LCCA submitted to licensing staff via email the operation's Corrective Action Plan.  The operation's LCCA provided communication indicating Suicide Screening will continue to be implemented per Minimum Standards to include the moment a youth is suicidal.  This includes additional screenings when youth verbalize self-harm.  The operation practices identifying risk factors (including ASQ) and protective factors, conducting a suicide inquiry, determining risk level and interventions, and documenting a treatment plan when warranted.  The Suicide Prevention line offers support and suggestions which the operation utilizes at present.  Assessment at a MH facility is also current practice and youth are taken when they meet criteria (critical school assessments, have a plan, verbalize needing to go, physical attempts, etc.)

12/04/2024- The operation's LCAA submitted to licensing staff via email the operation's Corrective Action Plan. The operation's LCCA provided communication indicating the operation Suicidal Screenings will continue to be completed, including immediately when a youth verbalizes it.


summary: 748.2951(d) - Evaluation-Results of each overall  annual evaluation made available to Licensing for review.

raw_content: The operation did not have an annual evaluation for review.

Category: Emergency Behavior Intervention

Correction Narrative:
12/09/2024- The operation's LCAA submitted to licensing staff via email the operation's Corrective Action Plan. The operation's LCCA provided communication indicating the operation has not experienced any Emergency Behavior Intervention incidents during the year of 2024.

Additionally, the operation's LCCA credited the operation's low incidents due to utilizing de-escalation techniques as well as encouraging positive behaviors. Also, the LCCA indicated de-escalation is utilized on a frequent basis by staff through implementation of SAMA.

The LCCA emphasized staff utilizing separation technique when residents are experiencing issues with positive interaction.


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

raw_content: The 2nd. Quarter EBI Report has not been submitted to Child Care Regulation.

Correction Narrative: The operation's 2nd. Quarterly EBI Report was submitted into the system.  The report was reviewed in CLASS.


summary: 748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs

raw_content: Based on information gathered during the investigation, it was determined a staff member did not provide appropriate supervision resulting in an adolescent running away.


summary: 748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit

raw_content: The fire extinguisher located in the kitchen, although still current on inspection, indicates empty (lost pressure) and needs to be refilled or replaced.

Correction Narrative:
07/30/2024-The LCCA submitted to licensing staff via email the operation's Corrective Action Plan indicating fire extinguisher was within timeframe for regulations with expiration date of August 2024.  Per Houston Fire, there was no solid rationale as to why the unit moved into red; however, it could have been due to the heat while staff and residents were displaced during Hurricane Beryl as reported by the operation's LCCA.  Additionally, the operation's LCCA reported the unit has been replaced as well as the other unit was retagged for the year.

07/31/2024-The LCCA submitted to licensing staff via email the photographs of the operation's two fire extinguishers (one new as well as one serviced) presenting in green indicating full as well as tags indicating service dates of July 2024.


summary: 748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed

raw_content: Based on information gathered during a review of the operation's documents, it was found two out two children's Discharge Summaries did not contain the reason medication was prescribed.

Correction Narrative: 05/16/2024- The operation's LCAA submitted to licensing staff via email the operation's Corrective Action Plan. The operation's LCCA provided communication indicating discharge summaries will be reviewed to ensure all required content is included in future discharge summaries.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1: Met
Condition #2:  Met
Condition #3:  Met
Condition #4:  Met
Condition #5:  Met/Not Met
-Quarterly Individual Meetings: (Met)
-Every 2-month observations of direct care staff: (Not Met)
Two staff have no documentation of observations (to occur every 2 months) conducted by the LCCA.
One staff has not had a documented observation conducted since Sept 2023 (required to occur every 2 months).

Correction Narrative:
01/29/2024-The operation's LCCA provided licensing staff via email the name of the mentor (LCCA) the operation as secured in providing mentoring services.  Additionally, RCCR staff identified the mentor's name as well as identified the mentor meets initial criteria for being a mentor.

02/20/2024-During Monitoring Inspection #3989066, RCCR staff evaluated the observation records as well as observations were completed, and compliance met as related to Condition #5 (every two-month observation of direct care staff).


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

raw_content: One child receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted a placement extension.

Correction Narrative: The operation submitted the variance request through the provider portal. The variance request for placement extension was processed, approved, and notification sent to the operation.


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 single evacuation plan in the operation was observed without a designated shelter inside location.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: In 4 out of the 4 files reviewed there was no documentation on the exterior of the record to indicate if the child had any chronic conditions.

Correction Narrative:
Unannounced inspection at the op. #3971110
Records reviewed; compliance met.


summary: 748.1221(c)(1) - Admission Assessment-Document why a particular piece of information is unavailable

raw_content: In 2 out of the 4 files reviewed the admission assessment did not have the all the required components such as the parents and siblings name, address and contact information. There was also no documentation in the file as required per minimum standards.


summary: 748.1271(3) - Emergency Admission Documentation-Include any allergies (food, medication, sting, skin allergies)

raw_content: In 1 out of 4 files reviewed there is no indication if the child has any allergies, there is a space on the admission assessment form for that to be documented however it is blank.


raw_content: Per condition 5, the operation LCCA should have conducted a meeting with all staff employed within 15 days of the start the probation period.  All staff that attended the meeting should have signed an attendance log.

Standard Number / Description: 745.8641 - Requirements during probation


raw_content: The staff list provided during the inspection was not consistent with the CLASS background check data. The staff list was last validated on the day of the inspection.

Correction Narrative:
Unannounced inspection at the op. #3971110
BGCs reviewed; Records reviewed; compliance met.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: The bathroom sink upstairs was not equipped with soap or anything for the children to dry thier hands.


raw_content: 4 of 5 children receiving emergency care services have been in care longer than 15 days without an extension.

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

Correction Narrative: The operation has implemented completing the extension at the time of intake and provided a form to demonstrate the placement extension.


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: Two children in care were charged with a crime by law enforcement on 05/06/2023, the incident was not reported to Licensing until 05/08/2023.

Correction Narrative: The operation sent the following statement, "TRIE will report within 24 hours"


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

raw_content: 1 of 2 children interviewed stated they have heard staff yell and use profane language towards children in care.

Correction Narrative: Three children were interviewed by RCCR Hannah Trahan and asked questions specific to staff yelling and using profane language. All three children stated none of the staff members yell or use profane language.


summary: 748.535(3)(C) - Child-care administrator responsibilities-Having system in place to ensure an employee is available for emergencies

raw_content: The operation did not have available staff to pick a child up from school when needed.

Correction Narrative:
The operation sent the following in regards to the citation: All allegations will undergo an AR. #2985299
Allegation: 748.1009 TRIE, II has always had enough staff to pick youth up and we will continue to do so.


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

raw_content: Children interviewed stated the staff do not check on them and are always on their phone.

Correction Narrative: On 06/01/2023, an in-person follow-up was conducted. Three children were interviewed and stated staff regularly check on them both day and night every 5-15 minutes and also stated a staff member is always upstairs with them. The operation sent the following in response to the citation: Allegations: 748.685(a)(4) Staff is monitored via cameras and will continued to be monitored to ensure the youth are receiving proper supervision as they always are.


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

raw_content: Staff member lied to RCCI investigator when asked if they went by a different name.

Correction Narrative: The operation has chosen not to hire individuals that are gender transitioning.


raw_content: 3 out of 4 children interviewed stated a staff member does not come upstairs to check on them. A staff member did not immediately intervene with a child who was self-harming. Additional supervision was not provided to a child who was making suicidal ideations and self-harming.

Correction Narrative: The operation e-mailed a statement saying they would provide supervision per minimum standards and staff members will ensure periodic checks of the children are conducted.


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 reported contacting the LCCA for onsite help and was denied.

Correction Narrative: The operation sent a statement regarding this citation: "No staff member asked for LCCA and was denied. Will continue to follow protocol."


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

raw_content:
The restraint report does not include the specific EBI administered or the specific restraint
technique used.

Correction Narrative: The operation sent a statement saying they would add the necessary criteria to the restraint reports.


summary: 748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care

raw_content: Three out of three child's admission assessment does not include a description of the circumstances that led to the childs referral for substitute care. Three out of three admission assessment did not state the services the operations plans to provide the child.

Correction Narrative: Operation stated they would add the missing criteria to the children's Admission Assessments and would be in the child's files to review.


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

raw_content: Three out of three serious incident reports reviewed were all missing some part of identifying information for the operation such as address or telephone number.

Correction Narrative: The operation e-mailed a statement saying they would add the missing criteria to their serious incident report documents.


raw_content: There is currently an open Abuse Neglect investigation involving a staff member. The operation was asked to remove the staff member during the course of the investigation. The operation has refused the safety plan that appropriately addressed the risk to children.

Standard Number / Description: HRC42.04412(a) - Interference with an investigation

Correction Narrative: The operation signed a new safety plan for DFPS on 2/22/23. The response received from the operation on 2/24/23 was "Will be requesting AR due to imprecise accusations. Will continue to follow MS as it relates to the accusations"


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operation is refusing to follow a safety plan requested by CCI stating they do not have any back-up caregivers.


summary: 748.4209(a) - Placement Extension-Child's service planning team must document the reason for the placement extension in the child's record

raw_content: In one child's file reviewed, the reason for their placement extension was not documented.

Correction Narrative: The operation e-mailed the following statement in regard to the citation: "Placement extension will be documented."


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

raw_content: There were 3 medication counts that were different than what was documented.


summary: 748.1217(b)(4) - Admission Assessment-At admission, must include any history of physical, sexual, or emotional abuse or neglect

raw_content: One child's admission assessment did not include their history of physical, sexual, or emotional abuse or neglect.

Correction Narrative:
The following statement was e-mailed to the operation in regard to the citation: "Added: history of physical,
sexual, or emotional abuse or
neglect on admit form"


raw_content: Five out of five kids interviewed disclosed staff yells at them, and three out of five kids interviewed disclosed hearing staff call a child in care mother a bad name.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative:
The operation e-mailed the following statement:
Staff member who allegedly engaged in the actions above, will take a course to address such behaviors. Additionally, all staff will be reminded to move about in an optimal manner that reflects the requirements of the Min. Standards.-TRIE, II . Additionally, a follow-up inspection was conducted at the operation. Multiple children were interviewed and stated humiliating, shaming, ridiculing, rejecting, or yelling by staff members does not occur.


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

raw_content: At the time of the investigation inspection, 1 out of 2 files reviewed was missing child's current service plan.

Correction Narrative:
The operation sent an e-mail containing the follow-ups for a different inspection and sent the following statement in regards to this citation: "The other from Ross is awaiting review bc we did have it. So we won't have it bc we are needing her sup to look at it." She stated she will be Administratively Reviewing the citation. On 01/27/2023, I e-mailed the operation stating "Good afternoon. I just wanted to let you know, even if you decide to administratively review a citation, something still must be sent in for follow-up purposes. By sending in something for follow-up, it is not an admission that you did anything wrong or admitting that you did not have the documentation in question." The operation responded "no prob" and "Follow up for Ross
Allegation: No CPOS for a youth.
Follow up-There was a CPOS dated for Aug 2022. Will AR
The Residence by Infinity Elite, II"


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: One staff file reviewed did not have the required 4 hours of preservice training.

Correction Narrative: The staff is now up to date on EBI training. The operation will ensure all staff receive the preservice training required per minimum standards in the future.


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

raw_content: One child's record reviewed did not contain their immunization record or proof the immunization record was requested.

Correction Narrative: The child's immunization records were e-mailed and placed in their file at the operation.


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

raw_content: Operation did not have written plan for protecting children in care from TB as stated in their policies/procedures.

Correction Narrative: The operation stated they would include a written plan in the staff's files who are exempt from TB.


summary: 748.4231(b)(3) - Admission assessment for emergency and respite care services-obtain as soon as possible information on the medications the child is taking

raw_content: One emergency placement child's admission assessment does not list the child's medications.


summary: 748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.

raw_content: One child's admission assessment reviewed did not include the child's trauma history.


raw_content: One staff member who was supervising a child in care was observed to be sleeping.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: One child's file did not indicate whether the child had any known allergies.


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

raw_content: One child's medication log did not contain the prescribing healthcare professionals name, the reason the medication was prescribed, the medication's name, the dosage and the strength.


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

raw_content: One child's file reviewed did not contain a preliminary service plan.


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

raw_content: A staff member harbored a child in care on runaway status and failed to report the child's whereabouts.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: A contractor worker witnessed the staff saying belittling remarks towards children in care.

Correction Narrative:
The operation sent an email 7/5/22 stating: Response: TRIE, II will ensure that staff refrain from subjecting youth to disparaging remarks. Although no one has heard or witnessed such action at the operation, staff will discuss during next meeting.
Follow-up inspection was conduccted on July 21st 2022. Children were interviewed and stated they have not heard staff say belittling remarks to children in care.


summary: 748.1101(b)(5)(B) - Child rights-participate in service plan within child's ability to manage info and have copy of plan Child 14 yo or older right to review/sign plan

raw_content: The child's service plan is not signed by the child, nor is there notes advising the child's desire/inability to not sign.

Correction Narrative: The operation sent the following statement: Operation will ensure signatures are obtained and or documentation requesting to do so is assessable and documented.


summary: 748.1439(b)(2) - Discharge Documentation-Send copy of child's background info, including progress notes for past 60 days, to next placement/caregiver within 15 days

raw_content: Case worker reported the agency did not provide the child's progress notes after the child was discharge.

Correction Narrative: The operation sent the following statement: Operation will ensure signatures are obtained, records are sent and or documentation requesting to do so is assessable and documented.


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

raw_content: Operation is not providing documentations in a timely manner.

Correction Narrative:
Response from operation:
Operation responds in timely manner when asked to produce documents. There haven't been any specifics shared so the operation isn't able to determine what exactly we are being accused of. However, we will continue to keep email correspondence as evidence for timelines. The operation steers clear of interfering with investigations and will continue to do so.


summary: 748.831(a)(3) - Orientation-Orientation must include the needs and characteristics of children that the operation serves

raw_content: staff orientation checklist is missing the topic of the types of children they serve.

Category: Training and Professional Development

Correction Narrative: Administrative review requested. The following statement was e-mailed in response to the citation: Operation will make sure the tests are fully completed and boxes are checked off. Where does it say that it MUST read The needs and characteristics of children that you serve particularly? And on which document?  This topic is most certainly incorporated several times-from the application process, into orientation and beyond. It is surely documented and discussed on our orientation packet. Why was this cited?


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

raw_content: The operation had the forms but had not filled them out for their awol's.

Correction Narrative: The following statement was e-mailed by the operation is response to the citation: Operation reviewed the policy on AWOL and now has clearer expectation. Will complete per MS.


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

raw_content: One discharged child's file did not list the circumstance of the discharge. The discharge summary also did not have the date or time the child was notified.

Correction Narrative: The following statement was e-mailed by the operation for follow-up for the citation:	Operation will document the d/c form in full.


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

raw_content: Two out of three child files reviewed contained conflicting information on multiple documents.

Correction Narrative:
Administrative review requested. The operation e-mailed the following statement as follow-up for the citation: Operation will put forth efforts to make sure the data is accurate and make notes/consult with worker when they conflict.
  The operation documented what the youth reported in person, not per paperwork. The paperwork is confusing/conflicting sometimes from DFPS, however, we document what we see or what the youth reports. Caseworker will be contacted for follow-up when warranted.


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

raw_content: Three out of three child files reviewed did not contain an immunization record.

Correction Narrative: Administrative review requested. The following statement was sent in response to the citation: Operation will continue to document when vaccines aren't accessible and continue to document the request from workers. School nurse had immunizations on file from State database and previous school records. Their records are in operations possession via email. Caseworkers did not send them.


summary: 748.361(d) - Personnel records-The system for maintaining all records must be uniform throughout the operation

raw_content: Required documents for files were not all kept in one consistent place for review.

Correction Narrative: Administrative review requested. Owner/administrator e-mailed the following in response to the citation and requested an administrative review : "We keep records on the computer AND on paper. Where does it specify that that is prohibited? They are accessible either way."


summary: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: In 1 out of 2 staff files the employee needed the refresher EBI course by 3/7/22 and has not completed it.

Correction Narrative: The operation e-mailed the following statement as follow-up for the citation: Operation will ask employees to complete refreshers in enough time-where they don't lapse.


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: Background checks have never been validated.

Correction Narrative: Background checks have been validated.


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

raw_content: Stair well bannister was missing piece.

Deficiency Narrative: Stair well bannister was missing piece.

Correction Narrative: During a walk-through, the missing bannister piece has been replaced and there were no other physical cite concerns.


summary: 748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care

raw_content: One child's admission assessment did not include a description of circumstances that led to the child's referral for substitute care.


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

raw_content: One child's admission assessment did not include a determination of whether the operation can meet the immediate needs of a child.


summary: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

raw_content: During the walk-through, poisonous chemicals were observed to be accessible to children in care.


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: One employee file did not have an up to date drug test.

Correction Narrative: A drug test was conducted by the operation for the staff member and a copy of the results were e-mailed to me.


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

raw_content: PLSP did not sign and date the 1 assessment that was completed.


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

raw_content: No documentation was completed for 2 out of 3 child files reviewed.

Correction Narrative:
The operation e-mailed a statement which read:

The items have been rectified and plans such as revising the forms have been completed to decrease the chance of the deficiencies occurring again.


summary: 745.4151(c)(6)(A) - Discipline-An applicant or employee's consent to submit to drug testing is required as a condition of employment

raw_content: One staff file reviewed did not have the signed consent form for a drug test.

Correction Narrative: A signed drug testing consent was e-mailed to me for the staff member who was missing the document.


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: One staff members file did not contain a statement signed and dated that they read a copy of the operational policies.

Correction Narrative: The operation e-mailed a signed document which stated the staff would abide by the operations policies and procedures. It was signed by the staff member and the operation sent a statement saying the document has been placed in the staffs file.


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

raw_content: Two staff member files reviewed did not have a high school diploma or GED.

Correction Narrative: The operation e-mailed the staff members high school transcript and a statement stating the transcript has been placed in the staff members file.


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

raw_content: One staff member file reviewed did not contain a job description..

Correction Narrative: The operation e-mailed a job description for the staff members file who was missing one and the operation also e-mailed a statement which said they would ensure job descriptions would be in all staff files in the future.


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

raw_content: Medication log is missing a designated area for signatures for who administers the medications.

Correction Narrative: A revised medication log form was e-mailed and contained all of the necessary criteria.


summary: 748.313(1) - Serious Incident-child death, substantial physical injury, suicide attempt, -document if EBI used within 48 hrs prior to incident

raw_content: Need serious incident report that contains all of the criteria.

Correction Narrative: A revised serious incident report form was e-mailed and approved.


summary: 748.121(1) - Abuse and neglect policy - required annual training for employees

raw_content: Abuse/ neglect policy does not include required annual training for employees.

Correction Narrative: Revised abuse/neglect policy was e-mailed to me.


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

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


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

raw_content: Need an unauthorized absence log.

Deficiency Narrative: Need an unauthorized absence log.

Correction Narrative: A revised unauthorized absence log was sent and compliant.


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

raw_content: Form does not contain the address and phone number for the person the child is discharged to.

Correction Narrative: A revised discharge form was sent and contained all of the necessary criteria.


summary: 748.105(3) - Personnel Policies - Develop written professional staffing plan

raw_content: The staff schedule in the staffing plan should specify which days staff members will work.

Correction Narrative: A revised staffing plan was e-mailed and compliant.


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

raw_content: The administrator is not on the payroll as of today.

Correction Narrative: Ms. Fontaine became the LCCA as of 11/26/2021.


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

raw_content: Discipline policy does not include a statement that discipline of any type is not allowable for infants.

Correction Narrative: Revised discipline policy includes a statement which says discipline is not allowed for babies.


summary: 748.1437(4) - Discharge/Transfer Documentation-Must include copies of child's service plans while in operation's care for the past 12 months

raw_content: Form does not contain a designated place that mentions whether the child's service plans were given.

Correction Narrative: Revised form has a designated place to discuss whether the child's service plans were given.


summary: 748.121(5) - Abuse and neglect policy - Actions that the parent of a child who is a victim of abuse/neglect should take to obtain assistance & intervention

raw_content: Abuse/neglect policy does not list the actions the parent of a child who is a victim of abuse/neglect should take to obtain assistance and intervention.