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

raw_content: The operations food pantry was observed to have several expired food items that were not discarded.

Correction Narrative: Per email from Administrator, the pantry was cleaned out on 5/13/25. All items were marked with visible expiration dates. All items that expired in 5/2025 or earlier were thrown away on the day of inspection. Overnight staff will clean out pantry once a week to ensure food in pantry is not kept past their expired date.


state: TX

facility_name: The Childrens Home of Lubbock ES and AC

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

raw_content: A caregiver did not supervise a child in care according to the child's plan of service which lead to an injury.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: Per email from Administrator, a staffing will be held to discuss supervision boundaries for each child placed at the shelter at team meetings. Counselors and other employee's who supervise children will be included in all meetings. The shelter employees will inform another CHOL employees of children's supervision guidelines or concerns according to their service plans. All children's service plans will be updated with supervision concerns and discussed with staff during the duration of the child's stay at the shelter.


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

raw_content: Duing the inspection, three out of four 72 hour preliminary service plans reviewed were not completed and signed within 72 hours of placement.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: Per email from Administrator, a meeting was held with each case manager individually to discuss the importance of completing the 72-hour preliminary service plan within time frame as well as all documentation in a timely manner and on time. They discussed methods of working ahead, staying on top of paperwork, organization of schedules and prioritizing tasks. Moving forward the Unit Director will meet with case managers the day a child is placed to ensure time frames are discussed and a follow up the with the Case Manager will be conducted to ensure progress has been made on the due date for the preliminary service plan.


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

raw_content: A caregiver was not aware of a 3-year old asleep in her room resulting in the child being left alone and unsupervised at the operation.

Standard Risk Level: High

Correction Narrative: compliant


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: This standard was found deficient as part of a DFPS Investigation.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: 3 of 3 records reviewed were missing information on the exterior of the child record.  2 active and one discharge child record did not document chronic conditions, medication allergies or allergies.

Standard Risk Level: Medium High

Corrected at Inspection: Yes


raw_content: One of three Preliminary Service Plans was not completed within 72 hours of admission.

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

Correction Narrative: Case management were informed of the 72 hour policy. Case Management understand assessment must be completed within 72 hours and not 3 days. Copy of missing Preliminary plan was provided. In addition the new intake forms were developed and  will be utilized to document when the 72 hour assessment is due.   Staff will fill in time frame when intake paperwork  is singed and the child is admitted.


facility_name: Child Crisis Center of El Paso

summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: Staff member has not completed the first aid training.

Category: Training and Professional Development

Correction Narrative:
Operation provided documentation showing that employee had completed her training on 10/01/2025.
Operation has also submitted all the other trainings for the totality of staff hired to demonstrate this was an isolated incident.


summary: 748.4207(a)(1) - Placement Extension-if there is appropriate reason for continuing care, a child younger than five may continue placement for a total of 30 days

raw_content: Children in care do not have a waiver/variance submitted to extend placement.

Category: Emergency Care

Standard Risk Level: Low

Correction Narrative: Operation was very prompt to compose the waiver/variance necessary to extend the placement of the children at the operation. Operation was very understanding and agreeing with their commitment on meeting and adhering to all of licensing minimum standards.


raw_content: A child in care sustained an injury that required medical attention while playing. The staff member was preoccupied performing other duties in another room not supervising the children in care when the incident occured.

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

Correction Narrative:
All Direct Care Staff received a supervising responsibilities training on 9/5/25. during the training all staff were trained on proper supervising techniques, protocols, and supervising responsibilities and procedures.

Training was conducted by Director Andrew Castaneda and Jenny Garcia.

Attach is a copy of the sign in sheet for the Supervising Responsibilities training held on 9/5/25.

A physical follow up wad conducted on 10/06/25. There were no concerns observed with the children in care. All children are very young and non-verbal. Staff mentioned they do not have any concerns with their responsibilities as caregivers, and they understand their duties.


summary: 748.1757(b) - AP Prohibited for infants-Crib must be bare except for tight fitting sheet & crib mattress cover per 748.1757(c) for infant less than 12 months

raw_content: During the walk through of the operation, an infant was observed to be asleep in his crib in a swaddle blanket.


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

raw_content: Various staff members did not have their annual training for Trauma Informed Care and Psychotropic medication training completed on time.

Correction Narrative:
By Friday, August 1, 2025, Operation has confirmed that the Caregiver/s have completed the pending pre-service Trauma Informed Care and Psychotropic Medication training hours to achieve the total required hours.
All required Trauma-Informed Care training courses have been completed and documentation for each completed training course is available for review. An updated onboarding checklist will now include a section for required pre-service and annual trainings, requiring employee signature and acknowledgment of both initial training completion and annual re-training requirements. Shelter Supervisor and Assistant Shelter Supervisor will verify completion of all new hire training prior to assigning shadowing responsibilities. To ensure the ongoing effectiveness of training implementation, supervisors will conduct quarterly reviews.


summary: 748.1385(3) - Service Plan Review-Must document any achieved or changed objectives

raw_content: The service plans for children in care were not updated as required per minimum standards.

Correction Narrative:
As of Wednesday, July 9, 2025, after reviewing and discussing it was concluded that effectively immediately. Any changes to a child's required services would be reflected and updated within the children service plan.
Shelter Case Managers have been instructed and educated to ensure all service plans are correctly updated and accurate with child's most recent required services.


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

raw_content: Staff member does not have current normalcy training.

Correction Narrative:
The operation will have shelter leadership maintaining on-going evaluation of staff member's records, which will consist of implementing a system for monitoring training progress, it will include maintaining an active spreadsheet with training due dates. Additionally, a Training Whiteboard will be utilized to provide staff with easy access to information regarding upcoming and overdue training sessions. To ensure continuous oversight, monthly random audits of staff training files will be conducted to verify the ongoing review and compliance with training requirements.

The operation sent an email showing the training being completed for that staff member.

This information was provided by the administrator of the operation Andrew Castaneda.


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

raw_content: Staff member has expired training (05/04/2023)

Correction Narrative: Staff member conducted the psychotropic medication training on 10/19/2024.


raw_content: Staff last took normalcy training 08/30/23.

Standard Number / Description: 748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.

Correction Narrative: Staff conducted the normalcy training on 10/22/2024.


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

raw_content: Operation does not have physical address or phone number included in the report.

Category: Reports and Record Keeping

Correction Narrative: A new form was created that showed by adding the missing information from the incident report.


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

raw_content: Current EBI training expired on 03/26/2024.

Correction Narrative: Staff member completed the training on 08/18/2024. Staff received a certificate on that date.


summary: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: Personnel files are missing reference checks and employment history verifications.

Category: Personnel

Correction Narrative: Reference checks have been initiated for the employee, and employment verifications have been requested from previous employers


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

raw_content:
Staff does not have training documentation.
No preservice training.

Correction Narrative: Staff member's training file was updated to accurately note previously completed trainings and training file has been relocated and combined with personnel file.


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

raw_content: Staff does not have transportation training.

Correction Narrative: Staff member completed the training on 10/19/2024.


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

raw_content: Employee's previous training expired on 06/17/22 and it was renewed on 12/14/2023.

Correction Narrative:
Throughout their assigned shifts, shelter staff actively engage with this platform on multiple occasions. By utilizing this platform, the Child Crisis Center of El Paso aims to establish an efficient and effective training notification system by January 15, 2024.
This will be done by ensuring once the shelter staff log in to access the platform daily, they will receive important training notifications and updates. Furthermore, the management team possesses the capability to monitor and send notifications regarding upcoming required training through this platform. This ensures that all staff members stay informed, prepared and most importantly in compliance.


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

raw_content: A boxing stand with a boxing bag were placed in the recreation area of the shelter. This equipment is without support and not attached to the ground.

Category: Physical Site


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

raw_content: Staffed gave an inappropriate letter to one of the children in care. Staff also took pictures of himself with children, who were making obscene hand gestures.

Correction Narrative:
1)	Emphasis professional boundaries behavior staff and children through training upon hire.
2)	Bi-annual training on professional behavior between staff and children.
3)	Team leads will assist in monitoring interaction between staff and kids.


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

raw_content: Children's files do not have allergy information visible.

Correction Narrative: program Director met with shelter Supervisor and Assistant Supervisors on 5/17/2023 to retain on the process of documenting of children's allergies  in their files as follows. Allergies are to be documented at time of intake. A sheet of paper will be placed at the front of the child's binder stating the child has ro does not have allergies. a pink paper will be if they have allergies and will state what the child is allergic to. A white sheet will be placed if the child does not have allergies. Supervisors and assistant supervisors will audit files to ensure documentation is provided. A sticker will also be placed on the outside of the file indicating any allergies.


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

raw_content:
Inspectors found several expired products, products with no received or expired date.
Products were donated.


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

raw_content: An extensive amount of expired items, were found in the freezer and refrigerator, during the inspection.


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

raw_content:
During the inspection the boy's shower  was covered with limes scale deposits and mold.
One of the toilets had feces in the rim.
There were spotted areas of dirt/mold along the surface of the shower angels.


raw_content:
Several bicycles, damaged and without air in their tires.
The backboard of the basketball hoop is broken.
The storage in the playground outside, does not have any windows.
One of the nursery rooms has broken shades and the sealing is uncovered leaving wires and vents exposed.

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


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

raw_content: The children in care were interviewed and spoken to individually shortly after the incident occurred.

Correction Narrative: staff were reminded during monthly meeting 8/30/21 that once an incident is being reported to licensing no one including the therapist will speak with the children involved until we receive notification that the investigation has been completed.


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

raw_content: 2 children in care displayed inappropriate behaviors while being transported on field trip.

Correction Narrative: The Child Crisis Center has implemented a transportation procedure which all staff are required to comply when transporting children. The procedure requires 2 staff to be inside the vehicle when transporting more than 6 children. One staff will seat in the middle lane, single seat next to the sliding door to monitor the children while the other staff member does the driving.


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

Deficiency Narrative: The children in care were interviewed and spoken to individually shortly after the incident occurred.


raw_content: Upon inspection of the kitchen, there were expired items found in the pantry.

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

Correction Narrative: Director stated the pantry was checked for any expired or unlabeled products to be removed. It was checked by the Team Lead, Shelter Supervisor, and the Director of Operations and everything is up-to-date.


raw_content: Observed several food items in the refrigerator and in the pantry that were not labeled and expired.


facility_name: Bayes Achievement Center

summary: 745.8641 - Requirements during probation

raw_content:
Condition #1-Not Met
Condition #2-Met
Condition #3-Met
Condition #4-Met
Condition #5-Met
Condition #6-Met

Correction Narrative:
The following corrective action was sent via email:
A final list of remaining employees will be compiled to prioritize getting any remaining teaching parent screenings completed in January upon return from the holiday office closures.


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

raw_content: Pre-employment screenings were observed to be completed after employees were hired.

Correction Narrative:
The following corrective action was sent via email:
The HR department has received training to clarify how to complete verification of employment for new staff members per licensing recommendations.


raw_content:
Condition #1-Met
Condition #2-Met
Condition #3-Not Met
Condition #4-Met
Condition #5-Met
Condition #6-Met

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative: Staff supervisors are now required to ask staff members direct questions about the severity of the incidents being reported to help them better prioritize notifications to admin staff. This will ensure that future serious incidents are reported timely.


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

raw_content: Employee files were observed to be missing documentation of attempts to contact references, and in some cases, there was an insufficient number of attempts made.

Correction Narrative: The LCCA met with Human Resources and discussed how to clearly document when contact is made and little/no information is provided by the contact. Discussed timeframes for making attempts to reach previous employers-current method was spread too far out and hard to track. Discussed 9/1/25 changes that all employment provided on an application must be verified, not just past five years.


raw_content:
Condition #1-Met
Condition #2-Met
Condition #3-Met
Condition #4-Met
Condition #5-Not Met-Employee observations were not conducted in accordance with the conditions that have been imposed.
Condition #6-Met

Correction Narrative: All observers are now clear on this matter and will communicate with each other on their observation schedule. In addition, the shift supervisors have been added as observers to conduct observations on the weekends.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: Results of pre-employment screening were not documented in an employee's file.

Correction Narrative: Following inspection, Administrator met with HR department personnel and reviewed the standards regarding previous employment screenings for new hires. The team member who is primary in conducting verifications stated that their current practice for conducting and documenting their verification attempts, and the steps supported the expectations of the minimum standards.


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

raw_content: A child who was admitted into care on 02/15/2022 did not receive dental care until 01/10/2024.

Category: Child Care

Correction Narrative: The LCCA emailed the following corrective action: The nursing supervisor has now changed how the medical reminders will be addressed in their electronic records and closed out to ensure an appointment has been made. Nursing will also document in the record any obstacles to scheduling time sensitive required documents.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: Child files were observed to be missing TB exam documentation.

Correction Narrative: The operation is implementing a more uniform practice in how and where electronic documents are stored, so they can be easily located.


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

raw_content: Children in the staff reported that one or more staff members have been observed sleeping during the overnight shift.

Correction Narrative: Inspector conducted an in-person follow-up on 06/06/25. During a walk-through of each of the houses, inspector observed child/caregiver ratio to be in compliance and no supervision concerns. On June 9, 2025, the agency's administrator inspector reported that a quarterly staff meeting was held on June 6, 2025, about staff staying awake during the overnight shift. All night staff members attended the meeting.


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

raw_content: Both the victim and the other collateral children in care that were interviewed made similar outcries that a staff member used a cell phone to tap them on their heads to redirect them.

Correction Narrative:
Physical follow up was completed at the operation on 5/27/2025.  I spoke with Administrator as well as staff.  The staff member confirmed that he had been re-trained by administrative staff regarding safety care, documentation training as well as discussing discipline and consequences at the operation.  On 5/21/25 a training was held with identified employee. Review of de-escalated interventions and strategies. Review of verbal and physical prompting techniques. Review of approved discipline techniques.
A copy of the agenda, who was preset, and the trainer was provided by the director and uploaded into the documentation library.


raw_content: During the investigation, it was reported through multiple interviewees that multiple staff were overheard using profanity.

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: Administrator Vanessa Eckenrode emailed a corrective action plan that detailed a training will be conducted on the upcoming shift change to address professionalism, mindfulness, and the expectations of Bayes for their employees.


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

raw_content: Neither of the four employee files reviewed were observed to have an annual Suicide Training.

Correction Narrative: Each of the four employees completed their annual Suicide Training and certificates were emailed to inspector.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: A staff member documented that a staff bent a child's fingers back causing the child pain, but the incident was not reported to the abuse/neglect hotline within the time frame required by minimum standards.

Correction Narrative: On 10/23/2024 an email was received form the operation stating the following: Administrator spoke with the staff who submitted the report and the staff they asked to turn it in for them and reviewed proper procedure for submitting concerns.  Reviewed the options for reporting concerns including anonymous reporting (statewide intake and within BAC). Reviewed reporting methods available within BAC: paper form, electronic form, and ricog@bayescenter.com. Reviewed how to submit anonymous RICOG (paper is only option for this or email from unassociated email account) In addition, Supervisor reviewed with the staff in each residence the expectations and processes for reporting concerns.


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

raw_content: A medication log reviewed for one of six children did not show a documented amount of medication administered or remaining count from September 1st through 22nd.

Category: Medication

Correction Narrative: The operation identified a glitch in their electronic system used to document administered medication, which was the cause of this error. The error was reported and corrected so that administered medication is now accurately documented.


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

raw_content: Six medication logs for four children in care were observed to have an inaccurate count of medication remaining documented on the log compared to the actual count.

Correction Narrative: The operation created a log where all count discrepancies will be documented on the log for a nurse to review. Staff will not update the system themselves. Nurses will also be completing a paper audit/med count for the following week to identify all affected records and make corrections as needed. Any identified errors will be addressed with the appropriate med administer.


raw_content: A child made an outcry of abuse by staff and the staff that it was reported to did not report it for several weeks.

Standard Number / Description: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

Correction Narrative: Reviewed the options for reporting concerns including anonymous reporting (statewide intake and within BAC) Reviewed reporting methods available withing BAC; paper form, electronic form, and rig@bayescenter.com. Reviewed how to submit anonymous RICOG (paper is only option for this or email from unassociated email account) In addition, Supervisors reviewed with the staff in each residence the expectations and processes for reporting concerns.


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

raw_content: One of the three transportation vans was observed to have a missing arm rest that exposed a small protruding metal piece on the side of the seat utilized by children in care. A second vehicle was observed to have an inoperable headlight.

Category: Transportation

Correction Narrative: As of 06/07/2024, both vans were taken out of the pool of vehicles used for transporting children. They will not be used for transporting children until the needed repairs have been made.


raw_content: Two of the five employee files were observed to have disciplinary actions detailing inappropriate discipline methods of children in care. These incidents were not reported to Licensing.

Correction Narrative: Administrator shared information for reporting with the Leadership Team. Administrator informed the team members that she must receive notification of all disciplinary actions, such as the ones identified in this inspection, so that appropriate reporting can be completed. HR Manager and HR administrator to ensure the Administrator receives notification/documentation when these actions occur.


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

raw_content: One of five employee pre-employment reference documents was observed to be missing dates of previous employment.

Correction Narrative: The administrator spoke with the operation's Human Resources Administrator regarding thorough documentation on employment verification forms when they are unable to obtain information from previous places of employment. Identified where on the form to document the due diligence efforts to obtain all information moving forward.


summary: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.

raw_content: Video surveillance revealed staff engaging in overt unfavorable physical contact with children in care.

Correction Narrative:
Inspector followed up at the operation on 06/06/24 and interviewed children in care who made no further outcries of abuse or neglect.

On 07/18/2024, the Administrator sent the following email correction:
The staff member involved has been terminated. Remaining staff has received additional training related to Bayes' discipline policy.


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

raw_content: Video surveillance revealed staff responsible for ensuring child safety present during the time that children in care were being subjected to excessive physical contact failing to intervene.

Correction Narrative:
Inspector followed up at the operation on 06/06/24 and interviewed children in care who made no further outcries of abuse or neglect.
On 07/18/2024, the Administrator sent the following email correction:
The staff member involved has been terminated. Remaining staff has received additional training related to Bayes' discipline policy.


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

raw_content: One of the four child files was observed to be missing a signed copy of the Child's Rights.

Category: Children's Rights

Correction Narrative: The operation provided a signed copy of the child's rights.


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

raw_content: A child in care was observed on video being struck in the face by a staff member as a form of punishment.


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: Staff was observed on video hitting a child in the face with a closed hand.

Correction Narrative: The staff member involved was immediately terminated. A new home supervisor was placed the resident. Remaining staff received coaching remaining to the incident, as well as the operation's policies/procedures, and expectations.


raw_content: Staff did not exercise self-control when disciplining a child in care by use of corporal punishment.

Correction Narrative: The staff member involved was immediately terminated after the incident was discovered and reported.


raw_content: Staff failed to properly supervise a child who is non-verbal. Child sustained a serious fracture of the right middle proximal phalarix (finger) that required medical attention and a cast.

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:
The administrator advised that all teaching parents who were responsible for supervision at the time of the incident were being re-trained on supervision and completing health checks.
A follow-up visit was conducted at the facility; the victim was hospitalized at the time due to an ongoing health issue. A staff member who was present during the time of the incident, Christian Garcia, was interviewed and confirmed that the re-training took place about two weeks ago and stated that there are now more staff members assigned to the house at one time.


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

raw_content: One of the six employee files reviewed was observed to be missing an annual training in Normalcy.

Correction Narrative: Updated training certificate was emailed showing completion on 06/12/23.


summary: 748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: One of the six employee files reviewed was observed to be missing an annual training in EBI.

Correction Narrative: EBI Training certificate was emailed showing completion on 04/10/23.


raw_content: Two of the six employee files reviewed were observed to be missing current driver's licenses.

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

Category: Organization and Administration

Correction Narrative: Updated driver's licenses were placed in employee files.


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

raw_content: Three of the six employee files reviewed were observed to be missing training in Trauma Informed Care.

Correction Narrative: Updated certificates for Trauma Informed Care were emailed showing completion on 06/14/23 for all three employees.


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

raw_content: A staff member hit a child in care.

Deficiency Narrative: A staff member hit a child in care.

Correction Narrative: A staff member hit a child in care.


raw_content: Staff member did not report a serious incident report in a timely manner to Texas Hotline.


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

raw_content: Multiple staff members questioned the children about the alleged incident before reporting to the hotline.

Correction Narrative: An unannounced visit to the operation was conducted to follow up on the deficiency received. Inspector spoke with two direct care staff supervisors, Enrique Hernandez and Kevin Butler, who stated that when a child makes an outcry, they do speak to the child to find out what occurred, review camera footage, report it to their superiors, and a report is then made to Licensing. Both supervisors denied interfering with investigations or conducting their own internal investigations. The administrator, Vanessa Eckrode, informed inspector that an Administrative Review had been requested. The administrator stated that she wanted to report exactly what happened, so she called Chase into her office to explain to him that she would be making a report, but needed to know exactly what happened, and that is when he described the alleged incident that took place. Mrs. Eckenrode stated that while multiple staff talked to him to try and find out what occurred, it wasn't to interfere with the investigation, but to only gain knowledge of the incident before making the report.


raw_content: Two of the six child records reviewed showed that children in care were provided a copy of the child rights after seven days of being admitted.

Standard Number / Description: 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

Correction Narrative: All case managers who track the completion of the intake child rights, were made aware of the deficiency and reminded of the 7-day deadline in the standards. Additionally, the parameters for this form, which in the electronic record, were checked and updated to a format that would reflect the 7-day deadline.


raw_content: Both seatbelts on the second row of Vehicle #037 were observed to be inoperable. One seatbelt in vehicle #028 on the second row was observed to be inoperable.

Standard Number / Description: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

Correction Narrative: Operation made the corrections by providing pictures; Van #37 seatbelts were corrected on 6/28/22. New part ordered for van #28 on 6/29/22 and Van #28 broken part replaced and seatbelt functioning 6/20/2022.


summary: 748.2901(2)(A) - Triggered Reviews-Review if child is personally restrained 4 times within a 7-day period, unless otherwise ordered or recommended in advance

raw_content: One of the eight child files reviewed was observed to be missing 2 Triggered Reviews.

Category: Emergency Behavior Intervention


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

raw_content: Caregivers did not provide line-of-sight supervision for two youths in care as required by their service plan.  As a result two youths went into a bedroom for approximately ten minutes before being noticed.

Correction Narrative: On 05/11/2022 corrections received from operation. The employees on duty when the lapse occurred all received corrective action/coaching on 04/01/22.  Program Coordinators were present in the residence in the evening for the next shift to provide support and coaching for the home Supervisors.  Supervisor meetings were conducted on 04/25/22 and 04/27/22 to discuss incident and specifics.  PAC policy was and expectations regarding supervision of students and following student specific supervision needs were discussed.  Home supervisors to review with the staff they supervise.  Shift Supervisors to continue to provide support and coaching to Home Supervisors with house routine and maintaining supervision.


raw_content: An employee was observed on video forcibly picking a child up from his chair and dragging him by his pant leg, and in another video, pushing this same child in care out of his chair onto the floor and hitting him.

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:
The administrator advised that the staff member involved in this incident has been terminated. A shift supervisor has been stationed in this residence in addition to the Program Coordinators having an increased presence in the residence to provide support and coaching to remaining staff.

04/25/22 and 4/27/22-Supervisor meetings were conducted to review the specifics of this investigation. Standards, operation policies, and expectations were discussed. Supervisors are to review with staff.
05/09/22 and 05/16/22-Annual EBI Training was conducted with all staff. Within the training appropriate interventions were taught.

A physical follow up (Interim) was conducted on 03/30/22, in which staff and residents were interviewed; there were no concerns.


raw_content: A staff member used physical force to push, punch, drag and twist a childs arm behind their back as an inappropriate response to behaviors demonstrated.

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

Correction Narrative:
The employee involved in this incidnent was terminated.
May 9th and 16th all Teaching Parents and Home Supervisors received annual EBI Training. Within the training, appropriate de-escalative interventions were taught and practiced in addition to the practice of tag out when becoming frustrated and/or when a colleague prompts you to tag out.

A physical follow up (Interim) was conducted on 03/30/22, in which staff and residents were interviewed; there were no concerns.


raw_content: A staff member failed to exercise prudent judgement and maintain self-control when he used physical force to hit and push a child in care to the ground, and physically pull the child across the floor by his pants.


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

raw_content: Two staff members failed to document and report the incidents that took place with a child in care on 3/12/22.

Correction Narrative:
During the course of this investigation, documentation training occurred on 04/11/22 and 05/2/22 (All teaching parents and home supervisors). Discussed the importance effective and accurate documentation. Proper documentation of Behavior Incidents and Emergency Behavior Interventions were addressed. See attached training curriculum.

A physical follow up (Interim) was conducted on 03/30/22, in which staff and residents were interviewed; there were no concerns.


raw_content: A child in care was subjected to corporal punishment when a staff member used physical discipline as an inappropriate response to the child's behavior.

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

Correction Narrative:
The employee involved in this incident was terminated 2/9/2022.
Following the initiation of the investigation into this incident, Leadership had meetings with all home supervisors on both shifts (2/9/22 and 2/11/22). The employee's unacceptable behavior was identified and BAC's policy, procedures, training, and expectations for the care and treatment of our students was discussed. In addition, the expectations for all supervisors to lead by example and hold their staff to the standards of conduct expected was addressed.
On 2/16/22, Leadership met with all teaching parents on both shifts. The employee's unacceptable behavior was identified and BAC's policy, procedures, and expectations for the care and treatment of our students was discussed. Also reviewed was the procedure for reporting concerns to administration and/or TDFPS and the expectation that client safety is a priority and concerns must be reported.
The above content was also reviewed will all Teachers, counselors, case managers, and day staff during Recognizing and Reporting Abuse and Neglect Training on 2/18/22.


raw_content: A staff member failed to exercise prudent judgement and maintain self-control when he used physical force to kick a child in care as an inappropriate response to behaviors demonstrated.


raw_content: A child in care was subjected to physical discipline by a staff member.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: A resident was not released from a restraint after no longer being a threat to others.

Correction Narrative:
The employee involved in this incident was
terminated 7/16/2021.
Since the initiation of the investigation into this
incident, all teaching parents have received
annual restraint training. De-escalation and
prevention are elements of this training. These
elements received additional emphasis during
the training.
In addition, training is scheduled for July 27th
and July 29th with all teaching parents to
review BAC policies and standards related to
use of EBI and de-escalation/prevention.


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

raw_content: Staff failed to offer de-escalation techniques prior to attempting a restraint on a child.


summary: 748.2451(a)(2) - Emergency Behavior Intervention-Use personal restraint only if policies permit and requirements of this subchapter are met

raw_content: Staff  failed to follow the operation's EBI policy by conducting an inappropriate restraint, not using preferred de-escalation and not releasing a child from a restraint after no longer being a threat.


raw_content: A staff inappropriately restrained a 16 year old resident, resulting in an injury to the head.


summary: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force

raw_content: Staff grabbed a resident forcefully causing the resident to fall forward into a window, with his face pressed into a mat.


facility_name: EVERYDAY LIFE INC

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

raw_content:
 During the course of the investigation, it was determined that a child in care was
able to obtain keys to a vehicle and drive off the premises

Correction Narrative: During the follow-up inspection, the operation has implemented a sign-in and sign-out log for keys and has secured a lockbox to store all keys.


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: Upon reviewing the staff application it was discoverd there were no documenttaion showing the references were contacted.

Correction Narrative:
The Agency plan for increasing the oversight in Pre-Employment screening preparing to prevent in advance the possibility for future minimum standard violation at Everyday Life RTC.

The agency will contact each of the several references to verify that the applicant is suitable to work with or around children. The H R Director of Everyday Life checked all other staff records and implemented the necessary corrections.
The administrator will review the Minimum Standard and the policy and procedures concerning supervision.
All documentation concerning this plan of correction will be made available for licensing personnel to view at Everyday Life RTC. Inc. located at 6955 Broach Road Bryan, Texas. 77808.

Initial Date of Compliance- 09/20/2024 (no exception).


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

raw_content: The service plan of one child referred to the child as the wrong last name on at least 3 occasions. Also, the plan was dated to be completed on 3.2.24, however, all signatures were dated 2.2.24, the child's admission date.

Correction Narrative: Everday life provided a corrective action plan via email in regard to the 748.151(3) citation. IN the CAP EDL stated that will ensure each document that is completed has only information that pertains to that specific child. EDL will also ensure that all information will be accurate.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: One of the four children files reviewed showed the child did not have a TB test within 30 days of being placed. The child has been placed since April 2022 and still does not have a TB test.

Correction Narrative: Per email from the operation: "Everyday Life staff are trained and understand the purpose of this rule for TB test is to ensure documentation is received and placed in a child's file to keep children and caregivers at the operation free of tuberculosis. If the operation is unable to get in touch with the caseworker within required timeframe, the operation should schedule a TB test."  The operation has developed policy that a TB test must be received prior to or at intake an agreement must be made with the Director if the TB test will not be provided.


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

raw_content: Two of the four children's files reviewed did not have contraindications of restraint documented in the admission assessment.

Correction Narrative: per email from the operation: "Everyday Life will enhance the checklist for admission requirements and ensure that the admission document include a space for contraindication requirement. Everyday Life will indicate if new intake has contraindications of use of physical restraint. Everyday Life will review documents provided prior to or during intake. Special information and conditions related to implementation relative to contraindication of the use of implementation of a physical restraint will be documented in the admission.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: Operation personnel was made aware that a child in care may have been exposed to sexual abuse prior to being placed at that operation and did not report the learned information to the hotline as required.

Correction Narrative:
Everyday Life staff will report serious incidents and allegations of serious incident: any non-routine occurrence that has an impact on the care, supervision or treatment of children. This includes, but is not limited to, sexual assaults, suicide attempts, injuries requiring medical treatment, runaways, commission of a crime, and allegations of abuse or neglect or abusive treatment.

Every effort will be made to make sure that all serious incidents and/or allegations are reported at Everyday Life according to DFPS standard. QA will be done by the administrator. All staff will be trained on documenting and reporting serious incidents. All reports will be maintained in a binder and made available upon request. Each time we report a serious incident report, Everyday Life's Director of Administration will notify RCCR and Contract Manager.


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

raw_content: 4 child medication logs were found to have errors where the medication is not accounted for accurately.

Correction Narrative: Everyday Life staff has completed the DFPS Psychotropic Medication training, as well as Medi Pro Pharmacy coming to Everyday Life to train the staff. Everyday Life also has an agreement with the Medi Pro Pharmacy to dispose of all extra and unneeded medication, due to medication change. Every effort has been made to make sure that the medication count is accurate at Everyday Life, QA will be done by the Executive Director.  All training certificates will be placed in each staff personnel file and made available for review.


facility_name: Rob & Simon's Hawthorne House

raw_content: During an inspection, an employee file did not contain two reference checks to determine employment suitability.

Standard Number / Description: 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.

Correction Narrative: During an inspection, an employee file was reviewed and displayed two reference checks to determine employment suitability.


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

raw_content: During an inspection, a caregiver was observed on the phone while transporting children in care.

Correction Narrative: During an inspection, all staff were attentive with the children during movie time and in ratio.


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

raw_content: During an inspection, a caregiver was observed transporting six children in care.


raw_content: A serious incident report minimized the severity of an injury.

Correction Narrative: 08/04- Rob & Simon's Hawthorne house submitted corrections stating they will continue to train staff to ensure that documents will contain necessary information that is true, accurate, and correct.


summary: 748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes.

raw_content: During an inspection I observed a disconnection notice that stated the gas had been disconnected due to nonpayment.

Correction Narrative: During an inspection the administrator provided documentation showing the gas is no longer disconnected.


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on March 31, 2025, it was determined that:

(1)    your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)    12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 4/1/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 10/1/2025.


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

raw_content: During the walkthrough of the outdoor area, used unemptied paint containers, a metal bed railing, and an air conditioner were observed in an area where children play.


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, the thermometer in the refrigerator measured 65 degrees.

Correction Narrative: The operation has replaced the faulty refrigerator. The new refrigerator was found to be in good repair with a working thermometer.


raw_content: The operation's water was disconnected four times within the last seven months due to non-payment.

Standard Number / Description: 748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes.

Correction Narrative: The operation's water was in operating condition during the follow up inspection. The administrator stated she would be ensuring the utilities remain in compliance.


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

raw_content: During an HM visit rotted wood was observed outside as well as a hole in the wall.

Correction Narrative: During the follow up inspection I observed the rotted wood has been removed and replaced. The hole in the wall has also been repaired.


summary: 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

Correction Narrative:
During a review of a child's file there was not a Consent for Treatment with Psychotropic Medication in the file for Strattera which the child began taking on 9.15.24 after the doctor was contacted on 9.12.24 and the change was made to discontinue Intuniv and start Strattera.

A written follow up was submitted and physical follow up was conducted at the operation. The consent form for Treatment with Psychotropic Medication was reviewed and there no concerns.


raw_content:
During a review conducted on September 30, 2024, it was determined that:

(1)    your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)    12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Standard Number / Description: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

Correction Narrative: An HM extension was approved effective 9/30/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 3/30/2025.


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

raw_content: It was determined that the operation did not follow the Attachment A that included a safety plan pertaining to a child not being able to share a room with certain residents.

Correction Narrative: During the exit interview, it was discussed that J.O will not be sharing a room with anyone and that was actually his first time. The administrator informed me that moving forward, if it does come that J.O has to share a room, they will ensure to follow his Attachment A. Also, during my inspection, I observed J.O to not be sharing a room with anyone.


raw_content:
During a review conducted on March 26, 2024, it was determined that:

(1)    your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)    12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring.  Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 3/26/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 9/27/2024.


summary: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

raw_content: CCR arrived at the operation in December, after the incident occurred, and the operation did not have a written incident report to provide to CCR.

Correction Narrative: A corrective action was received from the operation that was shared with all staff members: "All staff at Rob and Simon's Hawthorne House are required to complete a serious incident report when administering first aid to a youth. Attached is the serious incident report policy. Utilize this as a refresher on the serious incident reporting protocol. These documents will remain on the board in the kitchen for immediate daily access."


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

raw_content: Based on the review of the investigation it was determined one staff member was left with a group of 10 children due to a second staff member leaving to assist another staff member with a restraint.


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

raw_content: Based on the review of the investigation it was determined that a restraint was conducted and witnesses other than direct care staff were present.


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: During a Heightened Monitoring visit the administrator stated that 3 children were positive for COVID however this was not reported.


raw_content: Medication was signed and documented as given prior to the child receiving the medication making the count inaccurate.

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

Correction Narrative: En email was sent stating, Rob and Simon's Hawthorne House will ensure that medication is signed out after administration of medication to children in care.  Administrator will follow-up to ensure that signatures and count is correct, and that there are no medication errors. During a HM inspection the operation proved no concerns regarding medication review.


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

raw_content: Child in care did not receive prescribed medication for 3 days due to running out of refills.

Correction Narrative:
Medication logs were viewed for 3 children and found to be in compliance. A medication count was also completed. The operation is keeping track of refills using the medication audit system they have in place.

Written correction received from the operation: Rob & Simon's Hawthorne House will ensure that refills are ordered and received timely.  Refills will be reviewed in daily staffings to ensure the refills are ordered 15 days before the resident is out.


raw_content: It was observed during the backyard walk through that the operation had one loose brown wood post in the yard, and four new light brown playground box post next to the metal shed.

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


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

raw_content: Two children in care reported a staff bent a child's fingers backwards as a form of punishment.

Correction Narrative:
Physical-Interviews of the children at Ford Elementary. Interviews are available in the Contacts.

Written correction received on 2/24/22
Rob & Simon's Hawthorne House will continue to train Caregivers in Discipline and Punishment.  Discipline and Punishment will also be communicated with staff during the beginning of each shift and at Staff Meetings.  Administrator, House Manager, and Compliance will ensure this task is being communicated to staff.


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

raw_content: 2 of 4 contraindication forms were missing from the binders.


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

raw_content: Two of 4 forms were missing their orientation checklist outside of the allotted timeframe.


summary: 748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child

raw_content: Parent orientation information is missing from 2 of 4 children's files reviewed.


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

raw_content: It was observed during the walk through that the operation had food being thawed in the kitchen sink.


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

raw_content: Children interviewed by A/N Investigator reported restraints with their limbs placed behind their back.

Correction Narrative:
The staff member involved in this incident is no longer employed with Rob & Simon's Hawthorne House.  Rob & Simon's Hawthorne House will continue to train in De-escalation/EBI's, as well as Safety when a restraint is necessary. Campus Manager, Compliance and Supervisor's will ensure that staff are properly using the proper EBI/ De-escalation methods.

Physical Follow up:
On 4/13/22, 3 of 3 children were interviewed at Ford Elementary from Rob & Simon Hawthorne House. Three of 3 children stated they have not seen or heard of any physical discipline has taken place at Hawthorne involving a restraint placed behind their back. Interviews will be available in the Chrono.


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: Staff violated a child in care from their right to be free of abuse, neglect and exploitation. Staff physically endangered a child in care.

Correction Narrative: Per BGC the staff was made Inactive as of 06/29/2021. Per the operation, the staff member involved in this incident is no longer employed with Rob & Simon's Hawthorne House.  Rob & Simon's Hawthorne House will continue to ensure that staff adhere to children's rights. Staff have been put in place to monitor children and staff to ensure that all children in care are free of abuse, neglect and exploitation.  Administrator, Campus Manager, Compliance, and Supervisor's will be responsible that staff adhere to Children's Rights.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: Staff members failed to report suspected abuse and neglect or exploration of a child in care after observing lumps on the child's head.

Correction Narrative:
Rob & Simon's Hawthorne House will ensure that allegations or indications of abuse, neglect, or exploitation of a child is called in to the hot line as well as reported to licensing representatives. Discussions of the importance of reporting, abuse, neglect, or exploitation has been added to house
meetings as well as monthly staff meetings to ensure the incidents are called in as soon as a staff member is aware.  The staff member involved in this incident is no longer employed with Rob & Simon's Hawthorne House. Administrator, Campus Manager, Compliance, Supervisor and PLSP will ensure that if a restraint is necessary, it will be done properly.


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

raw_content: Staff used an EBI as a means to get a child to comply.

Correction Narrative:
On 2/1/22 current residents were interviewed and no concerns were expressed.
2/2/22: Rob & Simon's Hawthorne House has staff in place to monitor staff and children in care.  This ensures that staff members are following EBI company policies, as well as DFPS minimum standards. This also ensures that EBI is not used to get a child in care to comply. The staff member involved in this incident is no longer employed with Rob & Simon's Hawthorne House.  Administrator, Campus Manager, Compliance, Supervisor and PLSP will ensure that if a restraint is necessary, it will be done properly.


summary: 748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing

raw_content: A caregiver placed his hands around a child's neck impeding the child's breathing. Also, it was not determined that the situation constituted an emergency, the caregiver failed to minimized the risk of physical discomfort, harm/pain during the restraint, and failed to use the minimal amount of reasonable and necessary physical force. It was also determined that the EBI was used as retaliation for the child throwing  a brick at the staff member.

Correction Narrative:
On 2/1/22 current residents were interviewed and no concerns were expressed.
2/2/22: Rob & Simon's Hawthorne House has staff in place to ensure that if an EBI is necessary, it will be done properly. EBI's are reviewed at monthly staff meetings, and Staff are trained by in house trainers monthly an external trainer every three months. The staff member involved in this incident is no longer employed with Rob & Simon's Hawthorne House.  Administrator, Campus Manager, Compliance, Supervisor and PLSP will ensure that if a restraint is necessary, it will be done properly.


summary: 748.313(2) - Serious Incident critical injury resulting from short personal restraint-document short personal restraint and precipitating circumstances/behaviors

raw_content: Serious incident documentation did not indicate that a restraint occurred, or include that the injury was a result of a short personal restraint.

Correction Narrative: Rob & Simon's Hawthorne House staff have been retrained in the importance of detail on a Serious Incident Report. Incidents as well as Incident Reports are monitored and reviewed by Supervisor as well as Campus Manager.  Administrator, Campus Manager, Compliance, Supervisor and PLSP will ensure that if a restraint is necessary, it will be done properly.


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

raw_content: A serious incident report reviewed did not contain information of  a short personal restraint that had been implemented. That incident report was signed by a staff member that had acknowledged the restraint had taken place.

Correction Narrative: Rob & Simon's Hawthorne House has assigned PLSP, and Compliance to follow-up on Serious Incident reports to ensure that reports are true, accurate, and complete. The staff member involved in this incident is no longer with Rob & Simon's Hawthorne House. Administrator, PLSP, and compliance will ensure that reports are complete.


facility_name: Renewed Strength, Inc. East

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

raw_content: There was no documentation of the restraint that occurred.

Correction Narrative: Staff completed a Complete Refresher EBI Course by a Certified SAMA (Satori Alternative to Aggression) Instructor 6 Days after the notice received on 6/20/2025. Administrator, Treatment Director, Case Manager, Facility Manager, Direct Care Staff	Completed on 6/26/2025. Copy of the training certificates completion was viewed during inspection.


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: Three children in care were to remain standing as a form of discipline after returning from runaway.


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

raw_content: Four children in care ran away from the operation in the night, staff was not aware of their absence until they returned in the morning hours.


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: During a review of records it was determined that EBI numbers were not reported for the first quarter.


summary: 748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking

raw_content: During the investigation while reviewing records, it was found that CPR/First aid training was expired on a caregiver.

Correction Narrative: A CPR/first aid training was conducted on 5/10/2024 to ensure compliance. Moving forward the personnel files will be audited at regular intervals to ensure compliance with this standard. (uploaded current CPR & First aid training to document library)


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

raw_content: During a walkthrough of the operation, it was observed that several hanging rods in the closets of the children's bedroom were loose and could be easily removed.


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

raw_content: During the investigation it was found that a serious incident was not reported to the caregiver timely.

Correction Narrative: Please refer to inspection # 3990467 for follow up. The operation has a scheduled meeting on 3/1/24 with the staff to address these concerns and implement a new process of immediate notification despite the required time frames to ensure notifications are not delayed. The new process will consist of all notifications occurring at the time the serious incident and not waiting the required time.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: During the course of the investigation it was determined that medication was not discontinued as needed.

Correction Narrative: Please refer to inspection #3990467. Weekly the administrator (or their designee) will check the medications for any discontinued or discarded medications and remove them when necessary.  A medication destruction form will be completed, and the medication will be returned to the pharmacy for destruction.  This is a also a condition of current probation.


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

raw_content: During the course of the investigation, the victim child admitted to having access to and using the hot tub at the operation. During the walk through of the operation the hot tub was observed to be unclean and unsanitary. Staff acknowledged being aware that the child had used the hot tub. The child was diagnosed with a UTI following the incident.

Correction Narrative: A follow-up inspection was conducted. The hot tub with jets will not be used by anyone and the Administrator will remove the faucet knobs and replace with plastic inserts.


summary: 748.2853(4) - EBI Documentation-Content of the post discussion, if applicable

raw_content: The post discussion with the child section is missing some elements - such as the content of the discussion, the date and time it was offered, and the date and time it took place.

Correction Narrative: On 8/21/23, George Grant contacted me and sent me proof that they emailed the correction for this on 6/29/23.  I was able to find the email in the spam folder.  This form is now in line with minimum standards and has been uploaded to digital storage.


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

raw_content:
During the walkthrough, the outside patio bench was damaged, and nails were visible, and perturbing from bench.
 Also, in one of the rooms, a chair was observed to be damaged on the seating area.

Correction Narrative: It was reported that the damaged inside furniture was thrown out, and the patio furnitiure has been fixed.


summary: 748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation

raw_content: A child was admitted not meeting the age requirements per the license.

Correction Narrative: According to the admission/discharge documentation the child is no longer in care. Child was admitted on 4/13/2023 and discharged on 04/16/2023.


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 call into the hotline a serious incident for the child in care J.M.


raw_content: The toilet in bathroom 3 does not flush.

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

Correction Narrative: During the follow-up inspection, bathroom #3 toilet is working properly.


summary: 748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly

raw_content: Final determination of this deficiency is pending compliance with fixing the damaged fence brought about by inclement weather.

Correction Narrative: The damaged fence, brought about by inclement weather, was accordingly fixed and repaired. Photos of the repaired fence was sent to the Inspector.


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: There is a background check listed as active however the individual is not employed at this operation, he is employed at a different location.


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

raw_content: Medication records were observed to not include the reason the medication or the prescribing physician's name.

Correction Narrative: During the follow-up inspection, children records were viewed and the physican's name and reason for medication was documented.


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

raw_content: A caregiver was observed to be out of ratio for at least one hour.

Correction Narrative: During the follow-up inspection observed 9 children with two staff.


raw_content: One of the restrooms had a water leakage from one of the handles in the shower.

Correction Narrative: The water leakage was stopped. The two restrooms are being completely renovated.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: In the child's records, there is no visible notation of the child's allergies status.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: One of two employee files did not have the qualifications of the staff member.

Correction Narrative: A variance request was submitted regarding the staff member's educational background.


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

raw_content: It was founded in this investigation the caregivers were not following the child's supervision requirements.

Correction Narrative:
On 07/11/2022 the inspector reached out to the administrator through e-mail for compliance plan. No response provided.

On 07/18/2022 the inspector followed up again through e-mail to the administrator for the compliance plan. No response provided.

On 07/20/2022 the inspector e-mailed the administrator to follow up on the compliance plan and reminded the administrator of potential re-citation. The licensing representative responded and stated they received the compliance plan on 07/11/2022. The compliance plan was in the inspector's spam mail.

The administrator provided a compliance plan on 07/11/2022. The action step taken in service training will be conducted regarding staff is aware of individualized supervision for each resident by 07/25/2022. This is immediately on-going.


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

raw_content: Medication administration was not documented for the full seven days prescribed.


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

raw_content: Raw pork product was left to thaw in the kitchen sink. Pork product was not sealed in a leak proof bag or container.


summary: 748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826

raw_content: Cat at operation does not have vaccines on record.


summary: 748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies

Correction Narrative: First aid kits were observed missing required items such as bandages, thermometers, antiseptic solutions..


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

raw_content: Children in placement are being left long periods of time without supervision.

Correction Narrative: Operation emailed night supervision logs. Logs will be placed in digital storage.


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

raw_content: Medication Administration Records for two residents have conflicting information regarding the reason their medication was prescribed. The medication log for two children indicated errors with the pill count on 4 separate occasions. There is one instance of the initials of the staff administering the medication not being legible.

Correction Narrative:
Medication training was provided for all employees on 1-7-22 including proper medication documentation, medication error reports and proper administering of medication. Medication audits will be conducted by facility manager and case manager to continue medication improvement.
Medication error reports were completed and submitted with previous request for information regarding this investigation.


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

raw_content: Two out of two personnel records did not have First-aid-CPR training documented for staff.

Correction Narrative: An email from the operation was received stating that a First/Aid training was held with all staff on 1/21/22. The training log and certificates for the employees identified was also received.


raw_content: One of two personnel records reviewed did not have documentation to show the staff meets minimum age for the position held.

Standard Number / Description: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

Correction Narrative: An email was received from the operation stating that the employee has provided the required documentation. A copy of the documentation was also provided via email.


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

raw_content: One employee does not have an active background check and is presently working for the faciity.

Correction Narrative: A review of the background checks for the operation shows that a background check was submitted for the employee identified on 1/14/2022.


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

raw_content: The thermometer in the refrigerator was seen to be at 48 degrees Fahrenheit and the freezer was seen to be at 3 degrees Fahrenheit .

Correction Narrative: A email was received from the operation indication that the thermometer for the freezer and refrigerator were replaced. A photograph showing the thermometer temperature within the required temperature range was provided.


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

raw_content: Two out of two personnel records did not have documentation of a TB screening for the employee.

Correction Narrative: An email was received from the operation showing the employees identified have completed their TB skin tests.


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

raw_content: One of three child records reviewed did not have the immunizations records.


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

raw_content: A switch  in the one of the bathrooms was missing the switch plate covering. An outlet in the classroom area was missing a face plate.


summary: 748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner

raw_content: It was found on the premises of the operation that there is an accumulation of trash and debris items located on the outer quarters behind the buildings.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: Staff at the  operation whom have provisional background checks with conditions, are not following their conditions concerning medication administration, supervision,  and Transportation.

Correction Narrative: RCCR received the following from the LCCA: The facility manager will immediately adjust the  staff schedule and provide alternative Direct Care staff personnel to ensure adequate ratio and supervision per minimum standards


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

raw_content: The signatures of personnel administering medication were not included in the medical record.

Correction Narrative: CCR received the following from the administrator. An audit was completed by the case manager and facility manager. All signatures and initials were completed and the medication book maintained. To ensure ongoing compliance, a primary signature page for all  approved staff who administer medication was created and placed in the medical record.


summary: 748.685(d)(3) - Caregiver responsibility- Child participating in unsupervised activity - caregiver must provide/arrange/ confirm transportation to & from activity

raw_content: The operation did not provide, arrange or confirm transportation for a child in care.

Correction Narrative: The facility will verify all alternative forms of transportation for supervised and unsupervised off campus activities. All alternative forms of transportation will be verified in writing. No staff will transport a resident without first having verified with the facility manager that the child is approved for transport to and from activities. The agency will further verify transportation methods for school during the administrative and dismissal meetings. Should transportation continue to be an issue the facility manager will work with direct care staff to ensure they are informed about all bus routes, pick up and drop off times, as well as bus assignments.


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

raw_content: There are 2 dressers that are missing knobs

Correction Narrative: RCCL Inspector received the following 2 new dressers were purchased. Attached were photos


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

raw_content: Two beds did not have the protective mattress coverings.


summary: 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use

raw_content: The EBI policy did not list the use of short personal restraints as a type of restraint that is used at the operation.

Correction Narrative: RCCL Inspector received a copy of the updated EBI policy which included the short personal restraints.


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

raw_content: One of the sinks in a child bedroom did not have a drain stopper with a lift handle to release the water to drain.

Correction Narrative: RCCL Inspector received the following: Sink stopper was removed, water will now follow freely down the drain. Attached was a photo.


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

raw_content: 2 picnic tables were rotted on the legs,

Correction Narrative: RCCL Inspector Received the following. Adjustment were made to the benches


raw_content: There was a medication log that had an error, which resulted in the count being incorrect on the medication record.


raw_content: There is a hole in one of the walls located in a child's bedroom.

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

Correction Narrative: The hole was repaired a picture was attached.


raw_content: During the investigation it was noted that a child in care's medication log did not have a signature of the person who administrated the medication.

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

Correction Narrative: RCCL Inspector received the following from the Administrator: All staff were notified to sign and properly document for all medication being administered to residents. Staff signatures will be verified during medication audit.


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

raw_content: During the investigation it was noticed that the medication log for a child in care did not have an accurate count of medication on the log and in the pill packet.

Correction Narrative: RCCL Inspector received the following from the Administrator:Facility manager/ Case manager will ensure to complete an audit of medication to ensure that the medication count is correct on MAR and documented properly.


summary: 748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet

raw_content: The diagram was missing  the designated location outside the operation. The diagram was also missing the designated area to shelter inside in case of a threatening weather.

Category: Safety and Emergency Practices

Correction Narrative: The administrator provided RCCL inspector with a an updated diaphragm of the emergency evaluation plan. The are symbols to indicate the designated location outside the operation where caregivers and children are to meet.


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

raw_content: There was no thermometer in the first aid kit that is located inside the facility.


summary: 748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill

raw_content: 3 out of 4 residents reported that they have not participated in any fire evacuation drills, the operation more than several drills listed in that timeframe.

Correction Narrative: The administrator informed me that a fire and weather drill was completed with residents on 6/2/2021. The administrator will be ensuring this task is completed.


summary: 748.2101(7) - Medication storage & destruction-remove medication on/before the expiration date & destroy it in a way that ensures children do not have access

raw_content: There were 2 over the counter medications that were expired in the first aid kit that is house in the facility.

Correction Narrative: The pills were removed during the inspection. The Administrator, Treatment director, and Facility Manager will ensure the first aid kits are maintained to compliance.


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: Caregivers failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401

Correction Narrative: I spoke with current residents at the facility who expressed there were no staff members who have been seen sleeping while on shift. Also, the operation administrator has been conducting random checks of the overnight staff with no concerns noted in the recent past.


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

raw_content: Five children AWOL'd from the facility and staff were not aware that the children had left.

Correction Narrative: The operation is implementing a Q60 supervision form for overnight staff. The staff will fill out the form daily and ensure residence rights to be safe and adequately supervised. The executive director will once monthly on a random basis view a live circuit of the facility to ensure compliance with supervision standards. The logs were reviewed and all logs filled out up to 1/13/2022 live circuit viewed on 1/5/2022. Residents spoken with did not express concern for their supervision and stated they are adequately supervised during all activities at the operation.


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 member failed to demonstrate the use of appropriate de-escalation techniques, which ultimately led to a power struggle.

Correction Narrative: The follow-up information was provided after the Administrative Review occurred RCCR inspector received the following information from the Administrator: staff will be provided additional training on de-escalation techniques and managing aggression.


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

raw_content: In 2 of the personnel records reviewed there was no current job description.

Correction Narrative: Written Response: The treatment director will ensure that all personnel files includes a signed job description indicated that all personnel have been informed and acknowledged of their job duties. A copy of the missing job descriptions were included with the written response.


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

raw_content: There were 2 electrical outlets that are missing covers, one shower had several black stains at the bottom of the shower wall, a white baseboard needs to be repaired,  and a floor tile in one of the bathrooms needs to be repaired.

Correction Narrative: The electrical outlets were corrected during inspection. The shower has been cleaned. The base board has been repaired and the tile has been repaired. Photos of the repairs were also emailed along with the written response.


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

raw_content: There were no personnel towels or paper towels for the kids to dry their hands in one of the bathrooms.

Correction Narrative: Written Response: The Administrator and direct care staff will make sure that paper towels and toilet tissue are placed in the restrooms. .


summary: 748.1101(b)(3)(C) - Children's rights-Adhere to the child's rights to have religious needs met

raw_content: in 1 of 2 child records reviewed, the religious needs were no addressed. There were several other sections not addressed.

Correction Narrative: Written Response: Renewed strength will revise its bill of rights to mirror DFPS rights of youth.


summary: 748.1101(b)(6)(B) - Children's rights-The right to be free of unnecessary or excessive medication

raw_content: A child was given medication that was discontinued.

Correction Narrative: Staff will be in serviced on identifying medication and matching it to a current order for medication to ensure residents are not receiving discontinued medication. This in service will be completed on 5/14/2021.


facility_name: Clementine The Woodlands

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

raw_content: During a team monitoring inspection it was found that medications are not being logged with in 2 hours from administration.