raw_content: Bathrooms in Dorm 2 were observed to have shower knobs missing in both bathrooms and a broken door hinge. Bathroom in 4A was observed with mold on the ceiling. Bathroom in 4B was observed with a broken shower knob.

Standard Number / Description: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

Correction Narrative: Mildew had been cleaned from the ceiling in Bathroom 4A, and a work order was in place to repair the shower knob and door hinge. Showers in Dorm 2 were capped off to not be used, as there are two additional showers in the dorm to be utilized.


state: TX

facility_name: Gulf Coast Trades Center

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

raw_content: A staff member admitted to using profane language around children in care.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
As a correction the operations Administrator advised that the staff member who used profane language around a youth will be required to take refresher training on staff/student interactions and boundaries.
Follow up inspection #4070549 was conducted at the operation on 8/13/25 in which youth and staff were interviewed. It was determined the deficiency had been corrected based on the interviews.


summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: An incident that occurred on 05/04/25 involving a child in care pulling out a "shank" and threatening to stab another child with it was not reported to Licensing.

Category: Reports and Record Keeping

Standard Risk Level: Medium

Correction Narrative: The following corrective action was received: Supervisors were advised to discuss proper report writing with their staff to specifically identify contraband.  Moving forward, serious incidents will be reported according to minimum standards.


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

raw_content: An employee who was hired on 03/17/25 completed 8-hour shifts for On-the-Job Training on 03/24/25, 03/25/25, 03/26/25, 03/27/25, and 03/28/25, although the background check results were not received until 05/01/25.

Standard Risk Level: High

Correction Narrative:
The LCCA emailed the following corrective action:
HR will ensure that background check results are received prior to hiring new employees and prior to allowing them to be present at the operation.


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

raw_content: Employee lists provided to Licensing during probation inspections were observed to not have each of the active employees listed.

Category: Organization and Administration

Correction Narrative:
The LCCA emailed the following corrective action:
HR will ensure that all active staff are listed on the employee roster.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1-Not Met-Screening process was not complete for an employee prior to being hired.
Condition #2-Met
Condition #3-Met
Condition #4 -Met
Condition #5-Met
Condition #6-Met


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 adhere to work policies and procedures when bringing a weapon on campus.

Correction Narrative: The operation emailed the following corrective action: All staff at Gulf Coast Trades Center were required to sign the Standard Operating Procedure regarding Weapons and Firearms.  This will also be addressed in our next All-Staff training at the end of April.


summary: 748.3931(a)(1) - Weapons- Handguns are not permitted at an operation or during any type of activity.

raw_content: A staff member brought a handgun on campus.


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: The allegations are related to a DFPS abuse/neglect investigation.

Correction Narrative:
The operation emailed the following corrective action: All staff at Gulf Coast Trades Center were required to sign the Standard Operating Procedure regarding Weapons and Firearms.  This will also be addressed in our next All-Staff training at the end of April.
Inspector conducted FTF interviews with two children on 05/15/25, no further outcries of abuse or neglect were made.


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 child in care was able to access an unsecured weapon without staff's knowledge.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: One employee was observed to be delinquent in completing two annual trainings.

Category: Training and Professional Development

Correction Narrative: GCTC uses a training database to track training due.  The training courses in the database have been set to show required training due every 11 months.  This will ensure training is completed within the established timeframes.


summary: 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

raw_content: Caregiver was not awake during sleeping hours.

Correction Narrative: Gulf Coast Trades Center supervisors visit each dorm on campus once per hour.  They check in with an electronic devise that is monitored to ensure that these dorm visits are taking place.  This ensures that staff are monitored and given a break, if needed.  GCTC will continue this practice.


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

Deficiency Narrative: The allegations are related to a DFPS abuse/neglect investigation.

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


summary: 748.1693(c) - Nutrition-must ensure drinking water is always available to each child and served in a safe and sanitary manner

raw_content: A staff member reported that a previous staff member forced children to drink water out of the bathroom faucet and shower.


summary: 745.8485(a) - May not record, listen to, or eavesdrop on any Licensing interview or internal discussion

raw_content: Investigators reported being recorded while interviewing children and staff at the facility.


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 of the four employee files reviewed was observed to not have drug test results. This employee was on shift as recent at 02/22/24 supervising children in care.

Correction Narrative: HR will ensure that every newly hired employee has a negative drug test result prior to allowing the employee to supervise youth alone.  In this incident the employee had to be retested.  Results were received on 02/25/2025.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: Children in care reported not being allowed to call complaints into the ombudsman office without first contacting administrative staff.

Correction Narrative: Gulf Coast Trades Center will ensure all staff are aware of the protocols in place when youth request to make a hotline call.  Specifically, staff are to find a private area, dial the hotline number, step away from the area and allow the youth to speak to the hotline personnel.  GCTC currently has this practice in place and will continue with this practice.


raw_content: A staff member flipped the residents' bed and took their personal belongings out of anger.

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: Inspector conducted a follow-up visit and interviewed two children in care, neither of which made any further outcries of abuse/neglect. The operation emailed the following corrective action on 04/02/25: Expectations of direct care staff will be discussed during their shift meetings to include behaviors.  Staff will need to be relieved from their duty post, if needed, to walk away from the situation.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: A staff member forced a child to do sit-up and plank for breaking into his mother's vehicle.

Correction Narrative: Inspector conducted a follow-up visit and interviewed two children in care, neither of which made any further outcries of abuse/neglect. The operation emailed the following corrective action on 04/02/25: The minimum standard will be sent out to all direct care supervisors to go over with their staff.  This will be documented that every direct care staff has been trained on corporal punishment.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

raw_content: Family visits at the operation were suspended due to suspected illegal substances being brought in during the visits.

Correction Narrative:
Inspector conducted a follow-up visit and interviewed two children in care, neither of which made any further outcries of abuse/neglect. The operation emailed the following corrective action on 04/02/25: Students have and will continue to be allowed to make weekly phone calls to family on their approved visitation list.  In addition, when visitation is suspended zoom visits are made available and will continue to be made available.  Moving forward, if in person visitation has to be suspended, we will continue with our weekly phone calls and zoom visits.

AR will be requested.


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

raw_content: Several residents were found in possession of vapes at the facility. Search was not conducted thoroughly allowing vapes to be passed and used among residents on campus.

Correction Narrative:
Inspector conducted a follow-up visit and interviewed two children in care, neither of which made any further outcries of abuse/neglect. The operation emailed the following corrective action on 04/02/25: Training will be provided in our next All-Staff meeting on proper search techniques, as well as minimum standards 748.1113 and 748.1117.

AR will be requested.


raw_content: A resident was seen on camera footage breaking into multiple vehicles without staff presence or knowledge.

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: This standard was found to be in compliance during a follow-up visit.


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

raw_content: A serious incident report did not contain all required information.

Correction Narrative: The operation provided a follow-up regarding the citation for missing information in the serious incident report. Operation provided a new serious incident report form with clearly labeled sections for all required information and will be using this form moving forward.


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

raw_content: A child did not receive medical attention until days later following an incident which resulted in an injury.

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


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

raw_content: Staff did not intervene immediately while the children in care were horseplaying inappropriately, causing one child to become uncomfortable.

Correction Narrative: On 2/13/25, compliance plan received via email from operation stating the standard is being administratively reviewed. No additional corrections have been listed. An in-person follow-up was conducted on 02/24/25; two children and two staff were interviewed regarding supervision. Children and staff reported that staff immediately intervene and stop any horseplaying.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1-Not Met-Most recent employers were not contacted for two newly hired employees.
Condition #2
Condition #3
Condition #4
Condition #5
Condition #6

Correction Narrative:
The following corrective action was provided:

Moving forward, all applicant's prior employers will be contacted to meet the criteria going back 5 years or the last 3 employers.


raw_content:
Condition #1
Condition #2
Condition #3
Condition #4-Not Met. Not Met-There is no documentation indicating whether staff are meeting Minimum Standards in subchapters discussed and fulfilling job duties on the observation form created by the LCCA. There are also no signatures to show who conducted the observations or the minimum standards trainings.
Condition #5
Condition #6-Not Met. There is no documentation showing that staff acknowledged in writing that they received information following the monthly probation meeting between LCCA and Program Director.

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative:
#4.  The observation form has been revised to include that staff are meeting job duties as well as the addition of a signature line, see attached corrected form.  All current observation forms have been signed by the observer.
#6.  The LCCA and Program Director will be meeting soon and training will be conducted with staff after this meeting.  A sign-in log will be completed including an acknowledgement that staff received information regarding probation conditions.


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

raw_content: There are only two fire drills documented for the year; July 5, 2024 and August 29, 2024. The log indicates that drills were also conducted in January, February, March, and July, but they are not documented.

Category: Safety and Emergency Practices

Standard Risk Level: Medium Low

Correction Narrative: As drills are completed, all documentation will be maintained in the Human Resources office.  Using the yearly calendar, Human Resources will follow-up to ensure documentation is received when drills have been completed.


raw_content:
Condition #1
Condition #2
Condition #3
Condition #4-Not Met.  As of 10/09/24 there are 20 out of 85 staff members who have not taken the training.
Condition #5-Not Met. There is no documented plan to complete health and safety checks related to emergency drills, fire safety, and first aid kits showing how often inspections, evacuations/relocation plans must occur, or what each first aid kit must contain. There's also no documentation for specific dates of emergency drills, fire extinguisher inspections or first aid kits for the next twelve months
Condition #6

Correction Narrative: The LCCA emailed training records to show that the remaining employees successfully completed the required training. Also emailed was a documented plan to complete health and safety checks related to emergency drills, fire safety, and first aid kits showing how often inspections, evacuations/relocation plans must occur, and what each first aid kit must contain. LCCA also provided documentation for specific dates of emergency drills, fire extinguisher inspections or first aid kits for the next twelve months.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: On 10/04/24, a child in care expressed suicidal ideations to staff and three minutes later was observed by staff with a belt tied around his neck. This incident was not reported to Licensing until 10/08/2024.

Correction Narrative: To avoid late reporting in the future, a refresher course on Suicide Protocols will be conducted to ensure all direct care staff are aware of their responsibilities and protocols to be taken in serious situations.  This training will be conduct in October.


summary: 748.125(g)(2)(B) - You must not leave the child alone until a mental health professional assesses the child, in the event of a suicide attempt.

raw_content: A child who attempted suicide was not closely supervised before a suicide assessment was completed.

Correction Narrative: On October 25, 2024; refresher training was conducted to all direct care staff on Suicide Protocols.  Training included steps to be taken when a youth voices thoughts of suicide or attempts suicide.  In addition, all direct care supervisors were added to an email mailing list that notifies on-duty management of the on-call clinician for weekends.


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 suicide screening completed on a youth in care after a suicide attempt required supervision check-ins every 10 minutes, however per documentation received, checked ins were not done as required.

Correction Narrative: An in-person interview conducted on 11/7/2024 with youth confirmed heightened supervision.


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: Records reviewed show a suicide screening was not completed timely for a youth in care.


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

raw_content: An incident involving a child stabbing another child in care was not reported to Licensing.

Correction Narrative: AR has been requested.  GCTC will continue to report incidents as required when necessary.


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

raw_content: The airbag maintenance light was on for one van.

Category: Transportation

Correction Narrative:
The GRO stated:
This van will be taken off-line until repairs are made.  Staff will be given a manual for the vehicle being driven and be required to conduct a pre-trip inspection.  Any required maintenance shall be reported so repairs can be made.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: A practice severe weather drill was due by 4/13/24.

Correction Narrative:
The GRO stated:
The residential supervisor was given the required information and will conduct a severe weather drill be the end of the week.  Drills will be placed on a calendar for reminders of upcoming due dates so drills are not missed moving forward.


summary: 748.3273(3) - First Aid Kits-Each one must contain antiseptic solution or wipes

raw_content: Each operating dorm (5) and two vans were missing items in their first aid kits, including: antiseptic solution or wipes; or (2) Adhesive tape; or (5) Scissors; or (7) Thermometer; or (8) Tweezers.

Correction Narrative:
The GRO stated:
All first aid kits have been stocked with missing items and will be inventoried on a routine basis to ensure they remain in compliance.  GCTC would like to request an exclusion from adhesive tape as this can be used by youth in care to take contraband to their inner thighs.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: 5 staff files did not have complete pre-employment assessments.

Category: Personnel

Correction Narrative:
GCTC stated:
All files contained the pre-employment assessments to include employment verifications and references or documented attempts to obtain these.  An administrative review will be requested on this deficiency.


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: One service plan did not include the child's signature.

Standard Risk Level: Low

Correction Narrative: The service plan was signed and emailed to inspector.


raw_content: Children were able to use vape pens taken from staff's personal belongings inside the dorm area.

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

Correction Narrative: The Standard Operating Procedure for Use of Tobacco Products was sent to all Department Heads/Shift Supervisors to train with their staff.  This specific incident was simply an oversight on the part of this staff and was immediately reported to his supervisor.  Youth broke into his personal belongings and took the vape.  This employee was suspended for 3 workdays.  AR will be requested.


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

raw_content: A child's right to be free of neglectful supervision was not upheld when children in care were able to access and obtain vape pens from staff's personal belongings, kept in the dorm's office. This standard was found deficient as part of a DFPS Investigation.

Correction Narrative:
The operation stated:
The Standard Operating Procedure for Use of Tobacco Products was sent to all Department Heads/Shift Supervisors to train with their staff.  This specific incident was simply an oversight on the part of this staff and was immediately reported to his supervisor.  Youth broke in to his personal belongings and took the vape.  This employee was suspended for 3 work days.  AR will be requested.


raw_content: An incident report was not written when the Medical Director notified staff of a child cheeking his medication.

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Correction Narrative: Gulf Coast Trades Center management and Medical Director were exercising prudent judgement and ensuring that the level of supervision being provided would ensure the safety and well-being of youth.  No specific incident occurred.  GCTC was being proactive to ensure that medications were not being cheeked and handed off to other youth.


summary: 745.4151(c)(4)(D) - Mandatory drug testing-employee who is alleged to be abusing drugs must be tested within 24 hours

raw_content: A drug test was not given to a staff who was suspended from duties for having a vape pen in the dorm area.

Correction Narrative: According to the operation, This specific staff member was not drug tested because the vape pen that was stolen did not contain THC.  This did not rise to the level of reasonable suspicion.


summary: 745.4151(c)(4)(B) - Mandatory Drug Testing-All Employees are Subject to Random, Unannounced Drug Testing

raw_content: Caregivers stated they have not had any random drug tests.

Correction Narrative: All staff are subject to random drug testing.


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 service plan did not have a signature from the PLSP.


raw_content: Children in care were left unsupervised, leading to them obtaining and using a vape pen found in staff's personal belongings.


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

raw_content: Staff did not follow the operation's policy when they brought vape pens into the dorm area, where children were present.


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

raw_content: Staff were informed of possible abuse and/or neglect 3 days prior to making a report to the Child Abuse Hotline.

Correction Narrative: All employees will report serious incidents as soon as they are aware to the Child Abuse Hotline.  Training will be conducted on reporting these incidents.


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

raw_content: Several children confirmed a staff provided their personal phone for residents to use for communication.

Correction Narrative: The Standard Operating Procedure for Use of Mobile Devices was sent to all Department Heads/Shift Supervisors to train with their staff.  All staff will be required to sign that they have received training on this SOP.  Deadline for compliance is March 22, 2024.  SOP is attached.


raw_content: A child's right to be free of physical abuse was not upheld when a caregiver provided vape pens to children in care. This standard was found deficient as part of a DFPS Investigation.

Correction Narrative:
A physical follow up was conducted on 4.19.24. 4 children were interviewed and did not have any concerns regarding staff having vapes on campus or giving them to children in care. See interviews in chrono for inspection #
The operation stated:
The Standard Operating Procedure for Use of Tobacco Products was sent to all Department Heads/Shift Supervisors to train with their staff.  All staff will be required to sign that they have received training on this SOP.  Deadline for compliance is March 22, 2024.  SOP is attached.


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

raw_content: Several children confirmed staff provided them with a vape pin.

Correction Narrative: The Standard Operating Procedure for Use of Tobacco Products was sent to all Department Heads/Shift Supervisors to train with their staff.  All staff will be required to sign that they have received training on this SOP.  Deadline for compliance is March 22, 2024.  SOP Document was provided to CCR.


raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A staff member was found having inappropriate sexual contact and relationship with a 17-year-old child in care.


summary: 748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing.

raw_content: In 5 out of 5 files reviewed there is no demonstration in writing or documentation of physical technique demonstration the participant is allowed to use 748.869(d)(3)(B) to ensure the individual has mastered the material.


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

raw_content: It was found in 5 out of 5 personnel files reviewed no uniformity and mising training certificates.


summary: 748.869(a)(1) - Pre-Service Training- Self/Instructor-led training must include specifically stated learning objectives.

raw_content: In 5 out of 5 files reviewed there is no specific stated learning objectives available for review.


summary: 748.869(a)(2) - Pre-Service Training- Must include an evaluation tool to determine if the person has obtained the information necessary to meet the objectives.

raw_content: 5 out of 5 files reviewed did not contain an evaluation tool to determine if the person obtained the necessary information to meet the objectives of the training.


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

raw_content: In 5 out of 5 files reviewed the orientation is being combined with pre-service training.


summary: 748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record

raw_content: In 5 out of 5 files reviewed the orientation completion is not documented in the file and also does not include any information regarding components covered during orientation.


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

raw_content: In 1 out of 5 files there was no documentation for a caregiver having a HS diploma or GED from a program recognized by TEA, TPSAC, other state or equivalency from home schooling.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: It was found in 5 out of 5 staff files reviewed that staff was not also trained with a health care professional or pharmacist .


summary: 748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly

raw_content: During the inspection, it was observed in the cafeteria (kitchen area) that the fire extinguisher was out of compliance with the monthly inspection. The last inspection was April 2023.

Corrected at Inspection: Yes


summary: 748.3065(c) - Gas Inspection-Must comply with all corrections, conditions, restrictions specified in gas inspection report within timeframes specified

raw_content: It was found that the last time the operation had a compliant gas inspection was in 2020.

Correction Narrative: The gas inspection was completed on 9/18/23


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

raw_content: A child in care was not properly supervised by staff as a resulted cutting his wrist causing the child to need 9 staples.

Correction Narrative:
A staff meeting is scheduled for March 1st. Included in the agenda is a review of standard 748.685. The sign-in log will be turned into you as soon as every residential staff has participated in this overview.

Supervisor Deiserae Espinoza was counseled regarding to proper supervision process for youth in our care.


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

raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A staff member was found having inappropriate communication and sexual contact with a 17-year-old child in care.


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

raw_content: A Serious Incident Report was observed with the resident's names blacked out, with no knowledge of which residents or staff were involved in the incident.

Correction Narrative: Per the Administrator, action was taken immediately verbally to remind respective supervisors to remind staff not to cross out or black out any part of an incident report that is written and turned in for review. Also an email was sent to all staff from the assistant program director, Kenny Evans, on March 7th, 2023 to once again remind that crossing out or blacking out word is prohibited on incident reports. In addition, staff was reminded to use a resident's GCTC ID# when being referred to on an incident report written on another resident.


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

raw_content: Two Couch Counselors have been on shift four times in the past 2 weeks, while background checks are still pending.

Correction Narrative:
Per the Administrator, a new HR Director has been hired and a process of checks and balances was created to be sure that all paperwork is in order prior to the start of training.
As of 8/10 Lopez is no longer pending, Johnson remains pending but was taken off shift until bgc completely clears.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: The operation has not documented that a severe weather drill has been conducted since 11/28/21.

Correction Narrative: Documentation of a severe weather drill conducted 8/9/22 was received  from the operation.


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: On 2/17/22 it was discovered that a child in care was injured by another child on 2/10/22 and required medical attention. This incident was not reported to Licensing.

Correction Narrative: Staff received training regarding proper communication to appropriate supervisor/admin and documentation of injuries at all staff meeting on Friday, February 18, 2022. The sign-in and meeting information was reviewed at April probation inspection.


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

raw_content: The Administrator is not documenting if, how or when follow ups are being addressed after assessing documented incidents. A child with four documented incident reports for January 2022, where he exhibited high-risk behaviors was not placed on close observation or a safety plan to ensure the safety of the other children in care. The assessed incident reports are also not being signed after review of the Administrator.

Correction Narrative:
3/3/22: Per the Administrator via email, a new Incident Report Process Flow was developed by the LCCA. It was discussed at the last all-staff training on 2/18/22 as well as reviewed with each residential shift supervisor and couch counselor for the next several days after the meeting. Changes were incorporated to insure clear communication between departments. 3.	An on-call process for mental health concerns and emergencies has been created to include local GCTC therapists along with a backup corporate on-call therapist on the weekends. Attachments on the email include Sign in sheet from 2/18/22 meeting, revised Incident Report, and the Mental Health On-Call Process Flow.
4/11/22: At April Probation Inspection, incident reports were reviewed in compliance of their new reporting/follow up process.


summary: 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions

raw_content: Bagged spinach and shredded carrots used to make salad was observed expired.

Category: Physical Site


raw_content: A child was treated at the Emergency Room on 1/24/22 but not reported to Licensing until 1/26/22.

Standard Number / Description: 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


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

raw_content: A child sustained an injury and was not taken to see a medical professional for 6 days.


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 failed to utilize prudent judgement and maintain self-control when she wrote a sexually explicit letter to a child in care.

Correction Narrative: The Administrator expressed an increase in training regarding appropriate staff-student relationships is required during new staff Orientation and boundary related refreshers throughout the year, for existing staff as well.  At April probation inspection it was observed that Boundaries were discussed at all staff meetings for January and February 2022.


summary: 748.507(3) - Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties

raw_content: A staff member failed to comply with operation's policies related to maintaining appropriate boundaries with children in care.

Correction Narrative: At April probation inspection the Administrator, an increase in training regarding appropriate staff-student relationships is required during new staff Orientation and boundary related refreshers throughout the year, for existing staff as well.


raw_content: A staff wrote and sent a letter to a child in care, encouraging future sexual contact with him.

Correction Narrative: Per the Administrator, the following changes have been implemented: a log was created for the Medical Dept and for the Social Services Dept to be cross checked with documentation that Residential completes when a resident leaves the dorm. Also, shift supervisor rounds that are randomly conducted to supervise Coach Counselors have increased and will now be documented on the Residential form.  Copies of the logs were observed. Staff will be continuously trained on staff/student relationships. Staff Courtney Chambers was deemed Inactive in BGC 1/8/22.


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

raw_content: The vehicle used to transport children has an active alert to check the tire pressure.

Correction Narrative: A photo of the cleared sensor light on the vehicle was received 12/9/21, per the Administrator, the vehicle was inspected on 12/29/21, the Discount Tire technician stated there was no indication that anything further needed to be done to the vehicle.


summary: 748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care

raw_content: A Group Worker has not completed the annual TIC class.

Correction Narrative: Per the Administrator, a checklist of annual trainings has been created to be sure all trainings are completed in a timely manner.


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

raw_content: The LCCA does not have a Background Check on file for the operation.


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

raw_content: The LCCA has not completed an Orientation at the operation.

Correction Narrative: The LCCA will be included in the full new hire process, including drug testing, background checks, and orientation training.


summary: 748.533(a)(1) - Child-care administrator-Can be administrator for two operations if both operations are in good standing with Licensing

raw_content: LCCA is listed under two operations; one operation is on Probation, the other operation is in Application status.

Correction Narrative: A new LCCA was hired as of 11/1/21.


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

raw_content: A Group Worker has an affidavit on file but it was not signed/notarized.

Correction Narrative: Per the Administrator, a New Hire Checklist was created to be sure that all new hire materials are secure and in each employee file.


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: A new employee did not have a completed drug test within the past year.


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

raw_content: A serious incident was reported to Licensing but not documented at the operation.

Correction Narrative: Per HR, Although a serious incident report was made to licensing, a formal written incident report was not completed at the facility.  In the future, all necessary backup documentation will be completed on any incident occurring at the facility, whether reportable or not.


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

raw_content: There was a hole in the floor in a bedroom in Dorm 5B.


summary: 745.8641 - Requirements during evaluation or probation

raw_content: Condition 1: Compliant; Condition 2: Compliant; Condition 3: Completed; Condition 4: Compliant; Condition 5: Compliant; Condition 6: Not Compliant, the weekly Dorm inspection logs were not documented for the week of 9/5/21 and 9/12/21; Condition 7: Completed

Correction Narrative: Per HR, While the inspections were completed, the LCCA or designee failed to place them in the binder.  The LCCA did not maintain a copy for himself and the original inspection logs could not be located.  Going forward, the LCCA or designee will ensure weekly dorm inspection logs are documented and properly logged in the binder.  The LCCA or designee will submit a copy to the binder and an electronic copy will be maintained as a backup document.


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: Recreational calendar does not list the activities, indoors or outdoors, that the residents have the opportunity to participate in.

Category: Recreation Activities

Correction Narrative: A Recreational calendar was created in full detail and submitted for review. It was found to be in compliance.


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

raw_content: The evacuation diagram does not include (1) an actual floor plan of the dorm or (4) the designated area inside the dorm to take shelter for severe weather threats.

Correction Narrative: A new evacuation diagram was created and submitted.


raw_content:
Condition 1: Compliant- TA given based on task being completed by staff designated by the operation, not the LCCA/Designee.
Condition 2: Compliant
Condition 3: Compliant
Condition 4: Not Compliant   The task was being conducted on a monthly basis, not weekly.
Condition 5: Not Due
Condition 6: Compliant
Condition 7: Compliant

Standard Number / Description: 745.8641 - Requirements during evaluation or probation

Correction Narrative: Per HR Director, this was a miscommunication on the part of staff, an immediate correction was made to bring us into compliance.  Youth are being observed on a weekly basis, rather than monthly, as is the direction of Task #4.  GCTC takes pride in providing excellent services and safety to the youth in our care and appreciate your diligence in assisting us to obtain excellence.


summary: 748.1101(b)(3)(B) - Children's rights-Adhere to the child's right to receive educational services appropriate to the child's age and developmental level

raw_content: There are several rights missing from the Child's Rights provided to children at Orientation.

Category: Children's Rights

Correction Narrative: A corrected Child's Rights document was submitted by the operation.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: Severe weather drills were not documented as per standard.

Correction Narrative: Per the Residential Director Kenny Evans, the Emergency Operation Exercises form was revised. During Probation Inspection #3830911 the EOE form was observed in compliance.


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

raw_content: Fire drill evacuation times were not being timed properly.


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 check have not been validated since January 2021.

Correction Narrative: Per HR background checks are now being validated monthly. During Probation Inspection #3830911 the background validation date was 6/14/21 which is in compliance.


facility_name: Children's Village and Family Service Agency, Inc.

summary: 748.931(b)(2) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 1 hour normalcy.

raw_content: During the inspection, we observed two of four employee records reviewed lacked proof of annual Normalcy training.


summary: 748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves

raw_content: During the inspection, I observed one of two first aid kits reviewed lacked a pair of waterproof gloves.

Correction Narrative: On 12/3/25, the operation provided emailed confirmation of first aid kits containing missing items.


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

raw_content: During the inspection, I observed the operation has not had a fire inspection in over 1.5 years.

Correction Narrative: On 12/5/25, the operation provided a copy of a completed fire inspection.  The operation needed additional time for an inspection to be completed due to the operation not having a fire suppression system over the range oven in the house.  The fire marshal completed the inspection, granting the operation an additional six months to complete the renovation.


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

raw_content: During the inspection, I observed four of four employee records reviewed lacked Affidavit Form 2912.

Correction Narrative: On 11/25/25, the administrator located the necessary form and had staff sign the form by 11/21/25.


summary: 748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material

raw_content: During the inspection, we observed the loose fill under the playground equipment was between 3.5-5 inches  in depth.

Correction Narrative: The operation submitted a plan to have the old fill removed and new installed as vendor and supply availability allows due to the holidays.  The operation submitted a variance request as well to allow time to procure new fill.


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

raw_content: During the inspection, we observed two of two first aid kits reviewed lacked the first aid guide.


summary: 748.1385(7) - Service Plan Review-Must update the estimated length of stay and discharge plans, if changed

raw_content: During the inspection, we observed three of three service plan updates reviewed lacked updates to the estimated length of stay.  The children have exceeded the length of stay estimated in the admission assessment.

Category: Admission, Service Planning, Discharge

Correction Narrative: On 1/2/24, the operation submitted corrections indicating they will integrate the DFPS Form K-908-3300 service plan template into their service planning process going forward.  This template includes the requisite time frame updates.


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

raw_content: During the inspection, we observed one of the three children's med log records reviewed lacked the signatures of the administering staff.

Category: Medication

Correction Narrative: On 1/2/24, the operation submitted corrections indicating they would utilize updated medication logs including the requisite information which were developed on 11/19/24.


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

raw_content: During the Inspection, we observed two of three children's medication logs lacked documentation of the prescribing doctor's information on the form.


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

raw_content: During the inspection, we observed two of three child's rights reviewed lacked documentation of the date reviewed with the child.

Correction Narrative: On 1/2/24, the operation submitted corrections stating expectations for completing the date field of the Child's Rights form was reviewed with staff on 11/26/24 and with Cottage parents on 11/27/24.


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

raw_content: During the inspection, we observed three of three service plan updates lacked evaluations of effective strategies and goals for the children.  The service plans also lacked evaluation of Normalcy services.

Correction Narrative: On 1/2/24, the operation submitted corrections indicating they will integrate the DFPS Form K-908-3300 service plan template into their service planning process going forward.  This template includes the requisite update information regarding progress and effectiveness of strategies and techniques used to meet identified needs.


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

raw_content: During the after hours walkthrough, I observed three of four prescription medication logs lacked the reason the medication was prescribed.

Correction Narrative: On 11/19/24, the operation provided me with an updated medication log including a line for the missing Reason For Medication information.  The operation also submitted images of the current med logs with the Reasons for Prescription handwritten in.  The new logs will go into effect as new prescriptions start or when current medications begin a new sheet.  This brings this standard into compliance.


summary: 748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.

raw_content: Three of the four employee files read did not contain certificates for Medication of Administration.

Correction Narrative: All updated training certificates were sent and uploaded to document library


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

raw_content: During the inspection, I observed the refrigerator and freezer in the cottage to be lacking thermometers.  The house parent replaced the thermometers while I was present.


raw_content: During the inspection, I observed several medication logs to have entries with the initials of an individual administerinig the meds but no full name or signature.

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

Correction Narrative: On 4/2/24, the operation emailed updated medication logs with the name added to indicate to whom the initials in the cited med logs belonged.  Copies of these logs can be found in Document Library. This brings this standard into compliance.


summary: 748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required

raw_content: During the inspection, I observed the professional test for the smoke detectors was six days overdue.

Correction Narrative: On 4/1/24, the operation provided emailed documentation of the smoke detector test having been completed on 3/20/24.  This brings this standard into compliance.


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

raw_content: The main vehicle for the cottage did not have a thermometer in the First Aid Kit.


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

raw_content: The Health and Sanitation inspection was due earlier this month.  The most recent inspection was done on 8/8/2022 .

Correction Narrative: Completed on September 5th.


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

raw_content: One of the First Aid Kits had numerous packets of medication, which are required to be locked.


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

raw_content: A caregiver yelled at a foster child on more than one occasion.  He also put his hand on the younger sibling's neck while guiding him to his bedroom.

Correction Narrative: Documentation was sent to me from Administrator, Matt Rogers.  He reiterated what was done with the Litten foster parents after the case started. After extra trainings, coaching, and breaks, Children's Village decided that the Littens were not a good fit for their GRO.  Litten's last day was at the end of June, and they are no longer cottage parents with this operation.  The kids continue to thrive in the other home with the Cottage B parents.


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: On two of the child plans, the implementation date was marked to be 10 days before signatures, and one plan showed an implementation date that was 28 days before the parties signed the plan.

Correction Narrative: Mr. Rogers sent me the corrections which had reportedly been done on March 9th.  The new treatment planning forms as well as all the other corrections were uploaded to digital storage and show as compliant.


summary: 748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results

raw_content: On one dental exam, the bill and pictures of teeth were in the file, but there was no explanation of what was done or who the Dentist was.


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

raw_content: None of the child records showed any documentation that the CPS caseworker was notified at least two weeks in advance of the child's plan meeting.


summary: 748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available

raw_content: Three of the four children's records showed that the initial medical exams were done 4, 3, and  2 days late.


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 monitoring inspection, it was observed that the freezer in Cottage A did not have a thermometer.

Correction Narrative: On 1/17/23, I, Eric Sjerven, received emailed pictures of the replacement thermometer installed in the freezer.  On 01/16/23, the operation also provided a copy of the receipt for the thermometers by email showing the purchase date as 1/12/23.  This documentation and the associated pictures bring the facility into compliance on this standard and will be located in RCCR digital storage.


raw_content: During the monitoring inspection,the operation did not have documentation that the automatic fire alarm system in Cottage A had been tested within the previous 12 months.

Standard Number / Description: 748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required

Correction Narrative: On 1/16/23, I, Eric Sjerven, received an emailed copy of the fire inspection form signed on 3/14/22 clearly denoting the automatic fire and burglary alarm system had been tested and passed.  This record brings the operation into compliance on this standard.


raw_content: During the monitoring inspection, it was observed that the refrigerator in Cottage A did not have a thermometer.

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

Correction Narrative: On 1/17/23, I, Eric Sjerven, received emailed pictures of the replacement thermometer installed in the refrigerator.  On 01/16/23, the operation also provided a copy of the receipt for the thermometers by email showing the purchase date as 1/12/23.  This documentation and the associated pictures bring the facility into compliance on this standard and will be located in RCCR digital storage.


raw_content: During the inspection of Cottage A medication was found not be stored in a locked container.

Standard Number / Description: 748.2101(1) - Medication Storage-Store medication in a locked container


summary: 748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model

raw_content: In reviewing the medication logs for Cottage A  they did not have a updated medication log for the children in care.


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

raw_content: During the inspection five fire drill were reviewed. Out of the five fire drills reviewed one did not have the designated meeting area..


facility_name: Center for Success and Independence

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

raw_content: Pre-employment reference check must be completed before a confirmed hire.


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: Unauthorized Absence forrm does not have a section for a debreifing if and when the child returns from AWOL.


summary: 748.1501(a)(1) - Dental care-Children in care must receive dental care initially  according to the requirements in 748.1225

raw_content: Two children's records reviewed found no dental exam have been completed since admission, more than 90 days ago.

Category: Child Care

Correction Narrative: Effective immediately: Clients dental records will be required at admission. If a client has not had a dental examination within 6 months of admission an appointment will be scheduled within 30 days of admission to occur within 90 days. The results of the dental examination will be documented in the client's record.


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

raw_content: One of the staff records reviewed found staff did not receive trauma informed care training and normalcy training for 2024.

Correction Narrative:
Effective immediately: The Training Coordinator will email all staff **30 days before** all annual training (Trauma informed care, Normalcy etc.) deadlines, including: -Dates, times, and format (in-person/online). **7-Day Follow-Up**. A second email reminder will be sent **7 days prior** to the due date. B. Tracking & Compliance: The training Coordinator will maintain a **Master Log** of all staff training completions. Physical copies of certificates will be filed with employee records. **Non-Compliance Escalation** - If a staff member fails to complete training by the deadline: - The Training Coordinator will notify the **supervisor and Administrator** within **24 hors**. -The staff member will be placed on notice of correction until training is completed.
compliant staff. **Final Notice (1 Day Before Deadline). **Direct supervisor/scheduling coordinator notified if still incomplete.

** Consequences for Non-Compliance. ** -If training is not completed by the deadline: -Staff will be temporarily removed from the schedule until training is done.


summary: 748.930(a)(2) - Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training

raw_content: Two of the staff records reviewed found that staff member did not receive 50 hours of annual training for 2024 as required.

Correction Narrative: Effective Immediately: Annual Training Tracking System. Training Log. The Training Coordinator will create a **master spreadsheet/database tracking system. -Each staff member's completed hours. -Deadline for mandatory courses (e.g., EBI every 6 months). **Monthly audits** to flag staff falling behind. **Structured training Schedule** Mandatory Trainings First. ** Quarterly Breakdown: Staff complete~12.5 hours/quarter to avoid year-end gaps. ** Priority Order** 1. Critical Annual Courses**(suicide prevention, abuse and neglect reporting, trauma-informed care). 2.**Bi-Annual EBI refresher**(tracked separately) 3. **CPR/First Aid** (If expired) 4** Elective/Professional Development** (to fill remaining hours).


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

raw_content: Two of the staff records reviewed missing annual suicidal prevention training for 2024.

Correction Narrative:
Effective immediately: Mandatory for all caregivers and employees Annual Suicide Training: The Training Coordinator will maintain a centralized data log of all staff training deadlines. **Alerts will be set 30 days before each employee's annual due date**. ** Email notification** **30 Day Warning**. Staff receive an email with: -Link to the required training (on-line). -Deadline for completion. ** 7-Day Follow-up**. Reminder email sent to non-compliant staff. **Final Notice (1 Day Before Deadline). **Direct supervisor/scheduling coordinator notified if still incomplete.

** Consequences for Non-Compliance. ** -If training is not completed by the deadline: -Staff will be temporarily removed from the schedule until training is done.


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

raw_content: Multiple kids med logs were missing administration times.

Correction Narrative:
Op submitted corrective action plan: Nursing will have one-hour slots twice a week to review and audit the med admin book. Nursing will have a sign off sheet stating that a nurse has reviewed the med books and probs found for each client. Nursing will audit 10 % of clients weekly. Any missing documentation found will be reported immediately to administration. Staff administering meds will be required to double check that the admin time is recorded after every med pass. This will be done by reviewing the med logs immediately after completing pass to ensure no entry is missing time of admin.
Deficiency was related to documentation. No inspection is required.


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

raw_content: On multiple kid files, signatures/initals were missing.

Correction Narrative: Op submitted corrective action plan: Staff administering medication must sign full name at bottom of med sheet before administering the first med. After each administration, staff must initial next to time of administration to confirm the meds are given.


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

raw_content: It was found that 4 out of 5 children have seen or witnessed a staff member sleeping during shifts of providing care.

Correction Narrative: It was found that there are still allegations of staff sleeping.


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

raw_content: The operation has not submitted the quarterly EBI data reports for 2023 4th Quarter and 2024 1st Quarter.

Correction Narrative: EBI Quarterly Report reviewed in CLASS to have been submitted. Operation reported 1 personal restraint.


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

raw_content: A child's medication was not administered for 3 days due to it being misplaced by operation staff.

Correction Narrative: An email was received from the operation stating a new protocol was implemented effective 10/23/23 requiring two staffs' signatures for medication release.


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

raw_content: One out of four child's records reviewed were missing the admission assessment.

Correction Narrative: Operation submitted a correction action plan indicating effective immediately the Director of Clinical Services will instruct Admissions Team Lead and Admission Coordinators to ensure all pre-admission assessments are completed and charted when client is admitted.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: Two out of four children records reviewed suicide attempts were not reported to Licensing within the required time frame.

Correction Narrative: Operation submitted a correction action plan indicating Child Care Administrator will meet with all MHT's regarding notifying and reporting suicide attempts and serious incidents a abuse and neglect hotline. Employee training log was provided.


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: Two out of four children's records reviewed were missing proof of two weeks advance notification of service plan meeting.

Correction Narrative: Operation submitted a correction action plan indicating child's parent/guardian will get two weeks advance notice of the initial service plan meeting taking place. The meeting scheduler will email parent of meeting taking place, print the email, and place in chart.


summary: 748.1101(b)(3)(K) - Children's rights-be informed of search policies and be free of unreasonable searches and unreasonable removal of personal items

raw_content: Four out of four children's records reviewed were missing protection from unnecessary search information within the child's rights policy.

Correction Narrative: Operation submitted a correction action plan indicating effective immediately the client's bill of rights will be updated.


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

raw_content: Two out of four children's records reviewed were missing immunization record.


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

raw_content: Two out of four children's record reviewed were missing preliminary service.

Correction Narrative: Operation submitted a correction action plan indicating effective immediately, Director of Clinical Services will instruct all clinicians to complete preliminary service plan that addresses immediate needs of a child, supervision requirements, enrolling in school, or obtaining needed medical care or clothing within 72 hours.


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

raw_content: One of four children's records reviewed were missing child's initial service plan.

Correction Narrative: Operation submitted an approved correction action plan indicating the Director of Clinical Services will instruct all clinicians regarding initial service planning and completion requirements within 45 days of admission.


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: During the monitoring inspection, it was discovered the operation failed to remove 19 inactive employees from the people's list within required 7 days' timeframe.

Correction Narrative: Operation submitted a correction plan indicating all inactive persons who no longer are associated with TCSI will be removed from system within 7 days. An up-to-date employee roster to include volunteers and contractors was provided.


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

raw_content: A staff unnecessarily grabbed, pulled, and pushed a child as a means to get the child to comply.

Correction Narrative: Staff was restrained on EBI training 10/4/22. Additional training was provided for all the staff. Three children who were interviewed stated there has been no form of physical discipline at the operation.


summary: 748.2851(b)(5) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss what child can do to regain self-control in future

raw_content: During the inspection EBI reports were reviewed. Four of the four EBI reports reviewed were missing post discussions that included what a child can do to avoid EBI in the future and how a caregiver can assist. One child interviewed stated that they did not have a post discussion on ways that EBI can be avoided in the future.

Category: Emergency Behavior Intervention

Correction Narrative: EBI reports were modified to include post discussion with the children. Additional EBI training for all staff was conducted on 2/2/22 and 2/9/22. Both children interviewed expressed restraints being done appropriately and having a post-discussion with staff regarding the restraint.


summary: 748.3393(b)(1) - Toilets-Provide 1 toilet for every 8 children with individual privacy, including doors to individual toilet stalls

raw_content: During the walkthrough, it was observed that 1/3 restrooms was out of order for 1 week, leaving 21 residents to utilize 2 occupiable restrooms.

Correction Narrative: All toilets were working properly and there were enough bathroom facilities for the children currently placed there.


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

raw_content: A child in care was able to obtain a container of medication that was placed within arms reach and subsequently ingested a number of pills from the medication container.

Correction Narrative: CCR Inspector received the following information from the LCCA: Effective immediately the nursing department will  meet with direct care staff that resides over the administrating of the medications. Since the residents administer their own meds, the staff member residing over the med administrating will make sure all of the bottled medications caps are secured on the bottle and the blister packs are all stored away out of reach from the residents.


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

raw_content: A child's self-harming injuries were not documented and staff were not aware of them. Staff did not follow procedure the operations procedure of checking the sleeves when taking medication.

Correction Narrative: CCR inspector received the following information from the LCCA: Effective immediately, the nursing department will meet with each direct care staff member that resides over the med administrating and explain to them the importance of making sure they are following all polices and procedures of the operation during med administering. The nursing department will warrant the importance on checking the sleeves of the residents when the residents are administering  their meds.


raw_content: During interviewing, it was found that there are some blind spots in video surveillance when supervising children in care. Children also admitted that staff is not always able to see them when they want their actions to be concealed.

Correction Narrative: A physical follow up was conducted on 12/10/21 where supervision was observed. A written response on an updated policy regarding supervision and the surveillance cameras was received on 12/08/21.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: Witness stated that they've overheard staff make statements that she would hit the victim child.

Correction Narrative: A written follow up was received via email on 9/14/21 containing documents where staff were trained concerning proper disciplinary measures. A physical follow up was conducted on 9/29/21 during the operation's routine inspection. Children were interviewed concerning discipline. There were no concerns.


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

raw_content: A child in care reported a grievance to the operation and it was not reported to licensing until 4 days later.

Correction Narrative:
An email was received entailing the way in which the operation is to come into compliance and correct what has been deemed as deficient. The operation have made the proper corrections to educate staff and administration to ensure it does not occur again.

The most effective corrective action we made was completing the training titled Recognizing and Reporting Child Sexual Abuse: A Training for Caregivers. This training was required and completed for all care providers (therapists, nurses, direct care, and administration). This new training will be a part of the annual training curriculum moving forward


facility_name: High Sky Children's Ranch

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

raw_content: During the inspection a fire extinguisher door cover located in the shelter side of the operation, was observed to have a broken glass and the glass door covering was not secured properly.

Correction Narrative: High Sky GRO Director submitted compliance via email on 1/13/2025. A photograph of the replaced glass and secured clips holder for the fire extinguisher was provided.


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

raw_content: When a child in care presented with difficult behaviors, an employee covered the mouth of a child and pushed them away.

Correction Narrative:
RCCR inspector received compliance follow up from program director on 9/23/24.

Staff involved in citation was terminated on 8/16/24 for behavior towards child in care.

Following the incident, the operation implemented the requirement to have two staff members in the vehicle when transporting this child in care. Staff increased the Childs safety plan focus on prevention of behaviors during transport. The safety plan can be found in document library.


summary: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

raw_content: A child in care was not assessed by a medical professional after receiving multiple injuries.

Correction Narrative:
RCCR inspector received compliance plan from program director on 8/29/24. The operation will continue with health and well-being scans at the beginning of each shift to check for injuries or illness. If trends or patterns are identified with injuries to a youth, preventative measures will be put in place to reduce risk for the youth. When we have a serious injury, we will seek appropriate medical attention.

RCCR inspector conducted a follow up inspection on 9/10/24. Inspector conducted a walkthrough of the facility with no plain site concerns. The inspector spoke to three staff who stated when a child is injured, an incident report is made and a supervisor and case manager is contacted. Staff stated they check the children each day for bruises/scratches and injuries. They use a check mark system to document the checks. Staff stated supervision is discussed weekly in staff meetings and trainings periodically on injuries.


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

raw_content: Child in care had multiple injuries where staff were unaware of how the injuries were obtained. The child in care continued to be injured showing a lack of prevention and steps taken to ensure safety.

Correction Narrative:
RCCR Inspector received compliance plan from Program Director on 8/29/24. GRO Director and GRO Manager will increase unannounced in-home observations of staff interactions with youth. Staff will receive feedback on how they can improve active supervision of youth to ensure safety and well-being. If GRO Director or GRO Manager identify areas of risk, measures will be implemented to increase prevention of injuries.

RCCR inspector conducted a follow up inspection on 9/10/24. Inspector conducted a walkthrough of the facility with no plain site concerns. The inspector spoke to three staff who stated when a child is injured, an incident report is made and a supervisor and case manager is contacted. Staff stated they check the children each day for bruises/scratches and injuries. They use a check mark system to document the checks. Staff stated supervision is discussed weekly in staff meetings and trainings periodically on injuries.


raw_content: A child in care sustained multiple accidental injuries in a short time span. Multiple staff were unable to explain how and when the injuries are occurring

Correction Narrative:
RCCR inspector was emailed compliance plan from GRO Program Director on 7/25/24. Director conducted a training focused on creating a culture of safety on 7/18/24. The PowerPoint will be uploaded to document library. The Director met with the team virtually to discuss the standard and the importance of following through with active supervision. A copy of the standards related to supervision were provided to all staff for reviews.

RCCR inspector conducted a follow up walk through at the operation on 8/9/24. Staff were actively monitoring and in ratio with 4 children in care. Staff and children were both interviewed about supervision. There were no further concerns.


raw_content: Three children, two collateral staff members, and one professional collateral reported similar concerns of a staff member making a child uncomfortable when waking them up, calling a child a disappointment, and speaking to children about wanting to adopt them.

Correction Narrative:
RCCR Inspector received a follow up email from the GRO Director on 4/9/24. All staff reviewed a Prudent Parent Judgement training as well as their signatures indicating their understanding of their responsibilities. The training and staff signatures were added to the document library.
The staff involved was moved to another home with younger children, rather than teenagers, during the investigation.


summary: 748.4213(a) - Emergency Care Discharge Plan-if child in care for more than 15 days, must have a written discharge plan for child from person responsible for child

raw_content: Three children in care did not have a discharge plan from the emergency shelter.

Category: Emergency Care

Correction Narrative:
Program Director emailed the inspector the completed the preliminary discharge plan that will be used for children in care at the emergency shelter. The plan will include Anticipated Discharge Date, Emergency Care Services Placement End Date, Recommendations for Future Placement Type/Setting, Type of Care, Level of Supervision, and Services Needed, Efforts Reported by DFPS
Efforts of Current Placement to Prepare for Discharge/Transition, Immediate Needs Upon Discharge, Reviewed By and Review Date. The document is uploaded into the document library.


summary: 748.2951(a)(1) - Evaluation-Overall annual evaluation includes use and effectiveness of emergency behavior interventions at operation

raw_content: The operation does not have an overall operation evaluation for Emergency Behavior Intervention.

Correction Narrative: On 1/17/24, Program Director emailed the inspect follow up compliance of the GRO Overall Operation Evaluation. The evaluation states a total of four restraints were conducted in 2023. All restraints were in the emergency shelter, and all occurred in the month of July. One child was restrained three 􀆟times. Two staff conducted 2 of the 4 restraints. Both youth restrained were siblings. There were no notable injuries to youth. There was one notable injury to staff. The evaluation was uploaded to the document library.


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

raw_content: A caregiver failed to supervise children resulting in children engaging in inappropriate sexual behavior.

Correction Narrative: Compliance was discussed with the operation's administrator and the administrator sent an email stating what was discussed during the exit conference that they will increase supervision when only staff is on shift, medication administration will occur in common areas of the shelter, instead of in the medication room, to allow better line of sight for the caregiver. The administrator believes this change to their procedures will reduce areas of vulnerability in supervision.


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

raw_content: A child's medication log did not have the time for two different medications.

Correction Narrative: Received compliance from Christina Raines, Administrator. Christina stated the medication logs that were reviewed have been corrected. Christina attached the corrected documents on email. The medication logs for the medication Buspirone 5 mg and Isentress 400 mg were corrected. Christina stated that GRO Manager Carli Field met with the employee who made the errors and counseled her on proper medication log procedures.


summary: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

raw_content: A couple of children stayed at the emergency shelter past 90 days. A variance for a placement extension was requested until 8/31/2022.

Correction Narrative: Received compliance from the Administrator stating as discussed with RCCR Inspector, variances for placement extensions will be requested going forward. The administrator had inquired with RCCR Inspector about the need for variances on 8/30/2022 and began requesting variances on 8/31/2022 based on RCCR Inspector's guidance. The operation will ensure the children do not go beyond the 90 days of emergency placement without a variance request.


raw_content: Medication logs for a couple of children did not have the time when the medication was administered on 7/03/2022.

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

Correction Narrative: RCCR Inspector Sandra Melgar received email from the GRO Administrator stating that they remedied the medication log errors by speaking with the employees who were responsible for the errors noted in the inspection. The employees were able to cross-reference the other medication logs administered on the same day and same time and correct their error. Further, all employees were counseled on the importance of maintaining proper medication administration documentation. The GRO Manager is conducting more frequent medication log reviews to ensure errors are caught early.


raw_content: A staff member struggled, and continued to participate, in an incident with a child in care.

Correction Narrative:
High Sky's Shelter Director Christina Raines emailed Inspector Jordan Green the compliance plan on 5/20/22.
High Sky Children's Ranch takes matters of youth care and safety seriously and has created the following plan to achieve compliance with Standard 748.507 (1):

May 19, 2022: Staff attended a one- hour training focused on maintaining self-control during times of stress.

In June, staff will attend individualized developmental meetings with their supervisor. Staff will be asked to identify their strengths and weaknesses in areas of prudent judgment, self-control, and competence in approved techniques to manage youth behavior. The Shelter Director and Shelter Manager will provide feedback, monitoring, and further training as deemed necessary to improve their skill sets and ensure appropriate care of youth in care.

Monthly program meetings will focus on areas identified as needing further training in areas of competency, self-control, and prudent judgment.

Guidance and verbiage from the Technical Assistance Given will be reviewed with staff at monthly program meetings and when reviewing youth service plans to help caregivers make informed and careful decisions when interacting with youth to ensure safety and build trust with youth.

Non-prudent judgement and inappropriate interactions with youth will not be tolerated by High Sky Children's Ranch. Appropriate disciplinary and corrective action has been taken with the employee related to this incident and will be taken if any further incidents should occur.


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: A caregiver made inappropriate comments towards a child in care stating that by the child's 18th birthday the child would ended up in jail due to the child's previous arrest.

Correction Narrative: Received an email from Christina Raines, Administrator at High Sky Children's Ranch GRO stating that on 5/19/2022, she led a training with staff on managing their own emotions when dealing with youth behaviors. This training also covered in pre-service for all new staff and twice per year for existing staff. The staff member that was investigated was terminated on 4/26/2022, this is the same day the incident occurred.


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

raw_content: A caregiver used profanity towards a child in care such as "cunt", "bitch" and "little bitch".


facility_name: DePelchin Children's Center-Richmond Campus

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: During the inspection, it was observed that the fire extinguisher in the entrance hallway to have been used or has lost operating pressure.  The extinguisher must be serviced or replaced immediately with an equivalent unit.

Correction Narrative: The GRO responded with corrections by email and a photo dated 03/09/2023 displaying that the red stem that was cited on 03/07/2023 for the fire extinguisher in the entrance hallway that was used or lost operating pressure due to a monthly fire drill has been replaced and now showing compliance with a green stem now showing.


summary: 748.2855(a)(2) - EBI Documentation-Must include a description and assessment of the circumstances and specific behaviors that were the basis for EBI

raw_content: The documentation by the caregiver of the EBI did not reflect the actual video footage of the EBI.

Correction Narrative: This follow up was done by inspection. Please refer to Inspection #3925929. Chrono was also entered for this follow up. The agency followed up by changing from MANDT to TCI for the children in care, care giver responsibilities have been re-given to staff to read and sign again, cellphone policy all staff resigned. Staff and children were interviewed and confirmed training on new Restraint methods. Children had no concerns and made no outcries.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: A caregiver restrained a child by dragging him by his feet while another staff member grabbed his arms immediately after the child had fallen several feet onto a hard floor.


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

raw_content: A caregiver removed items that could have assisted a child in care with climbing down safely from a dangerous height, creating an unsafe situation which resulted in the child falling several feet and with the potential for being injured.


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

raw_content: After the child fell several feet the caregiver immediately restrained the child without attempting other less restrictive measures to calm him.


raw_content: During the course of the investigation this standard was found to be deficient. A Supervisor at the operation ordered the staff to perform a restraint as a means to get the child to comply or as means to discipline the child. The child was not a harm to himself or anyone else at the time of the request.

Correction Narrative: The agency has responded with an email on staff being re-trained on restraint protocols. All newly hired staff will also be trained as well to ensure safety in the future. a physical FWUP was  conducted on 2/6/23 #3926386 and staff and children were interviewed as well in reference to restraint or being mistreated there were no concerns.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: Three children expressed being restrained with their arms behind their back.

Correction Narrative: The agency will continue to self report in accordance with minimum standards. The new de-escalation training TCI was rolled out onto the floor as of 10/4/22 all staff were retrained.


summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: During this inspection it was found that this standard was found deficient and not complete by the agency.

Correction Narrative: The agency responded with corrections by email on how they will ensure all staff will conduct a debriefing discussion with the victim and maintaining records by completing the physical restraint report based on the standard within 48 hours.


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

raw_content: During the investigation of this standard was found to be deficient based on the statement of the victim and a collateral staff supporting he was in pain  during the restraint and was treated after with an ice pack.

Correction Narrative:
A follow up was completed for and staff and children were interviewed. Staff took trauma informed care and children were interviewed and confirmed no restraints or concerns. Staff stated that they discipline the children by using verbal warnings and then possible write and level drop
Serious incidents will be sent via email due to access limited with several staff being absent.


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: During the investigation it was found that the agency failed to report a serious incident to licensing in a timely manner on several incidents involving the victim.


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

raw_content: During the investigation it was found that the agency failed to report a serious incident to parents/caseworker in a timely manner on several incidents involving the victim.


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

raw_content: During this investigation this standard was found to be deficient due to staff using profane language and calling a child names in front of her peers as a form of punishment.

Correction Narrative: The agency has responded with compliance and ensuring safety for all children in care by implementing a new de-escalation technique called TCI. All staff and new staff have been trained with TCI by the agency and there has been a decreased in restraints since then. The agency has address concerns by re-training staff on how to de-escalate behaviors and do not use of profane language by monitoring the units closer with audio and cameras. Staff will held accountable by agency to follow rules at all times. During the follow -up inspection staff and children were interviewed to ensure compliance has been met and no concerns with restraints and profanity were expressed.


summary: 748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation

raw_content: During the investigation this standard was found deficient due to a staff member receiving multiple write ups related to being inappropriate and abusive with children with children in care. These concerns with this staff member were similar concerns to those that resulted in an RTB in this investigation.


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

raw_content: During this investigation this standard was found to be deficient due to staff being present within audible and visual distance of a child being abused and not intervening.


raw_content: During the investigation this standard was found deficient due to staff not providing a safe environment and threatening the well-being of a child by telling children to fight each other and by engaging with a child in a physically threatening manner.

Standard Number / Description: 748.685(c)(2) - Caregiver responsibility - provide a safe environment


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: During the investigation this standard was found to be deficient due to a staff performing a prone/supine restraint without attempting a less restrictive intervention first.


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: During this investigation this standard was found to be deficient due to staff physically harming a child in care. Staff received an RTB for physical abuse and neglectful supervision.


summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: During the investigation this standard was found deficient due to staff physically pinning a child to the wall by putting her forearm across the child's chest and neck and pushing her onto the wall.


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

raw_content: Excessive force was used during a restraint

Correction Narrative:
During the follow up inspection I interviewed five children residing at the operation. Five of the five kids interviewed stated that they have not been hurt during a restraint and did not feel any pain during restraints. The operation has re-trained staff on the appropriate use of force during a restraint and is continuing training for further development.

Staff involved in allegation was terminated due to using inappropriate restraints.


raw_content: During a restraint, child in care arms where put behind the back

Standard Number / Description: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back


summary: 748.3003 - Sanitation Inspection-Must keep most recent sanitation inspection report at operation; report must include name & phone number of inspector

raw_content: The health inspection provided was expired 8/31/21

Correction Narrative: An email was received containing the Health Inspection documentation. The documentation appeared to be updated. Compliance has been met.


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

raw_content: Staff failed to utilize prudent judgement and self- control while performing assigned tasks, when staff became physically aggressive with a child in care. Additionally, staff was negligent in failing to intervene when this occurred.

Correction Narrative: RCCR inspector received the following information from the LCCA: The staff member in question has been deemed unable to perform job functions at DCC. The incident was unprovoked and came without warning. DCC staff are trained thoroughly on the use of EBI and the behaviors that warrant the usage of physical restraints. Staff member in question was placed on administrative leave the day of incident and upon further investigation was terminated from DCC and is no ineligible for rehire. CCR verified that both staff have been listed as inactive and terminated.


raw_content: Caregivers s failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.001(4) (A)(iv) and §261.001(1)(C)

Correction Narrative: CCR inspector received the following from the LCCA: All DCC staff members will receive in-service and annual trainings on how to appropriately respond to Crisis situations and how to report any acts of abuse and neglect.  DCC will continue to train and support all staff members through this process and exhaust all efforts to ensure the children of DCC are safe and free of abuse and neglect. The LCCA stated the notifications to parent/Managing conservators were sent.


raw_content: A staff member utilized corporal punishment when a child in care was choked.

Standard Number / Description: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

Correction Narrative: CCR inspector received the following from the LCAA:Corporal punishment is not tolerated at DCC. Shift Supervisors to revisit this standard and have the staff to sign of stating that they have received and understand this information. I will also make sure that the documentation states who is responsible for monitoring these actions. CCR confirmed staff involved were terminated