summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: One expired medication was observed in Promise, and two expired medications were observed in Brave and Joy.  During the inspection, staff removed the medications and disposed of them.


state: TX

facility_name: Family Link Treatment Services, Inc.

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

raw_content: A broken toilet tank cover was observed in Brave.

Category: Physical Site

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: Walk though was conducted in Brave house, and the toilet cover was fixed. The operation has a binder for maintenance requests, and if something needs to be fixed, the staff reaches out to management, and management reaches out to the maintenance team.


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

raw_content: Opertion did not send the requested document in a reasonable timeframe. Multiple requests were made prior to the opertion, before the documents were provided to the investigator.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Correction Narrative: Staff were interviewed and stated that the training had been completed, and the following was discussed: getting documentation sent in in a more timely manner, and each home has a folder to help maintain completed incident reports. Training certificates were provided to the inspector.


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

raw_content: The operation was unable to provide documentation of an incident involving children in care being inappropriate. The operation staff confirmed that an incident report was completed, but it was never found.

Correction Narrative: On October 6, 2025, the operation sent an email showing pictures of the incident report folders that will be placed in each home. The opertion will have a staff meeting to address where to place the incident reports and who will be reviewing them. Training was completed on 10/14/25 and certificates were submitted to inspector.


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

raw_content: During the walk-through of the homes, all four homes had multiple items missing from the first aid kits.

Category: Safety and Emergency Practices

Correction Narrative: An email was sent to the inspector with pictures of the first aid kit and check checklist of what needs to be in them. The operation will have an overnight check on first aid kits daily to ensure they are staying in compliance.


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

raw_content: 2 out of the 4 homes did not have a floor plan for an emergency evacuation.

Corrected at Inspection: Yes


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

raw_content: The posted evacuation plan all four homes didn't have the meet up location documented.


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

raw_content: The posted evacuation plan at Promis House didn't have the meet up location documented.

Correction Narrative: Walk-through of Promise house was completed. The administrator updated the evacuation plan. Administrator stated monthly walk-through will be conducted in the homes to ensure that evacuation plans are posted and viable and have the designated meet-up location


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

raw_content: Staff did not have access to emergency medication.

Correction Narrative: Staff were interviewed and stated they have access to emergency medication. Staff confirmed the med givers are the ones to provide the emergency medication. Administration confirmed they updated the lock box so staff is able to have access to the emergency medication at all time. Inspector did a walk though of the home and confirmed staff have access to emergency medication


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 took children out for an unauthorized period of time.

Correction Narrative: Staff were interviewed and stated that all outing must be approved before they are able to leave campus once they are off campus staff must send pictures of their location. Staff had additional training for prudent standard to maintain compliance when it comes to going on outing. Staff confirmed training was provided.


raw_content: During walk thru child in care mae outcry staff had told another child in care to shup up. Staff did state they had told the child in care this.

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: Four children were interviewed and stated they have not seen or heard about staff telling someone to shut up. All four children who were interviewed indicated staff are nice to them.


summary: 748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible

raw_content: Children in care are wearing dirty clothes and shoes.

Correction Narrative: Four children were interviewed and observed to be clean and well-dressed. All the kids' shoes were clean, and there were no stains on their clothes. All the children who were interviewed stated staff gives them new clothes when needed.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: A child in care's car seat was expired and dirty.

Standard Risk Level: High

Correction Narrative: Inspect all the vehicles that were on campus. All car seats that were available were in compliance and clean. Staff who were interviewed stated that more car seats are being ordered.


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

raw_content: Hole in one of the bedroom closet ay Joy house.

Correction Narrative: A walk-through of Joy house was completed and no concerns were found. The hole in the wall was patched up and the house was clean. No kids are living at Joy House at this time.


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

raw_content: Child in care had a severe diaper rash and was not seen by the doctor until the next day.

Correction Narrative: Staff were interviewed and confirmed that training was completed for the Diaper Rash Protocol. A sign-in sheet was seen and the inspector verified that the training was completed. Staff confirmed they check diapers every 2 hours and if a rash is seen they notify the administration immediately.


raw_content: Multiple children confirmed staff yelling at them and shared their personal information with other kids without their permission.

Correction Narrative: The inspector interviewed two kids, and none were concerned about staff sharing their personal information or yelling. The inspector was able to interview one staff and confirm that training was completed on boundaries.


raw_content: Staff admitted to letting a child in care use their cell phone to look something up.

Correction Narrative: Two kids who were interviewed stated staff does not allow them to use their phones. Staff confirmed they had training about the use of cell phones and boundaries.


summary: 748.1101(b)(1)(C) - Children's rights-Adhere to the child's right to receive fair treatment

raw_content: It was confirmed a staff member shows favoritism towards residents by bringing individual gifts and food for children who the staff is close with and does not bring these items for another resident. The staff member uses this as a consequence to get back at the resident.

Correction Narrative: The inspector interviewed staff and kids at the operation. Staff confirmed that training on children's rights was completed. Staff stated they are waiting for approval to implement a reward system for the kids to help with behaviors. Three kids were interviewed one said the staff no longer works in the home and the other kids said they have not seen or heard about staff showing favoritism.


summary: 745.903(2) - Controlling Person - Submit Controlling Person Form to Licensing within two days after a person becomes a controlling person. See TAC 745.901

raw_content: Operation did not submit controlling persons for last two administrators, current board members and governing body.

Correction Narrative: The operation sent an email on 9/12/24 stating controlling persons and the Governing Body updated the CCR Provider portal on 09/11/2024. The inspector was able to verify controlling person was updated in class. Training was completed on 09/12/2024 where the TAC 745.901 was reviewed. FamilyLink- Legacy Ranch Management Staff will ensure that all changes to the Controlling Persons and Governing Body will be updated within the required time frame. The training was held training was between the administration since they are the ones that oversee Compliance and making sure the portal is accurate. The operation reviewed the TAC that was listed on the assessment so that they understood who should be listed as a controlling person. The operation understand that they need to make any updates moving forward within 48 hours of the changes.


raw_content: The inspector observed dog food, chips, and hair on the floor of one of the homes.

Standard Number / Description: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

Correction Narrative: Interview with staff confirmed that a training was conduct with the staff. Staff stated that the operation went over the citations that were given. Training topics consist of helping the kids with their chores and making sure staff maintain the cleanliness of the operation. A walk-through of the homes that had concerns was conducted. Walls were patched up, the dresser was removed from the children's room and the children still had enough space to put their clothes. Wires were covered and wall sockets were covered as well. Vents were cleaned and a re-paint was done. The refrigerator was cleaned and the food was labeled no safety hazards were observed. The outside window screen has been removed a new replacement has been ordered it was confirmed by the administration.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: During the walk through it was observed there was an unknown substance spilled in the freezer.


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

raw_content: Staff interviewed were not aware of the citation for medication. Staff confirmed there is no set plan in place when it comes to refilling medication. Staff confirmed they do not know who refills medications. Compliance plan was never received.

Correction Narrative: Two staff interviewed confirmed that the operation provided additional medication training. Two children interviewed confirmed they have refills for their medication and have not gone without taking their medication. The operation provided a compliance plan and stated they would provide additional medication training for staff if needed.


summary: 748.4011(3) - AP General requirements-Must never leave a child under eight years old unattended in a vehicle

raw_content: Staff admitted to leaving two children in vehicle unattended.

Correction Narrative: Staff interviewed confirmed additional transportation training was completed. Staff also confirmed if they need additional training the operation will provide additional training. A sign-in sheet was provided to the inspector.  Two children were interviewed and confirmed that they had never seen staff leave children in the van and stated that all the children must leave the van.


raw_content: Staff did not administer medication prescribed due to medication refills not completed in a timely manner.

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


raw_content: Staff did not administer a child's medication at the required time per the medication instructions and did not document the reason medication dosage was missed.

Correction Narrative: Two staff were interviewed and stated that the operation provided refresher training and additional training on how to document medication errors, refuse medication, and who to contact. Two kids were interviewed and stated the staff always gave them their medication in a timely manner when they needed it and they have not run out of medication since they have been here. The inspector reviewed the MARs for one of the homes and did not find any concerns. All counts were corrected and there were no missed medication errors.


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 staff witness indicated the operation director plus one other staff walked from the school to the residential area with at least 21 children in care. The director didn't know with how many children in care they were walking.

Correction Narrative: During the walk-through, it was observed that staff was in ratio of 1 to 8 with kids. Three kids interviewed all stated that staff is always with them and there is always enough staff. Two staff were interviewed and stated that they went over training for ratio. The operation went over with staff how important it is to stay in ratio at all times.


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

raw_content: Child in care admitted to choking another child in care and staff were not aware or present when the incident occurred.

Correction Narrative: During the walk-through staff was engaging with the kids in the living room. All the kids were in the living room watching TV. The staff was able to state how many kids they had in ratio and how many kids were in the home. The staff was also able to identify what supervision looks like to them.


raw_content: During the walk through I observed a long amount of dust in the light fixture in the restroom that children in care are using.

Correction Narrative: During the walk through I observed that the light fixture was clean and no safety concerns were viewed


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

raw_content: A staff member threw a child onto the bed and child sustained physical injuries.

Correction Narrative: During the interview with administrator, it was stated that the staff was no longer there. All staff has been informed regarding the RTB and the importance of ensuring all children are supervised and nurturing touch is the only touch children receive. The staff interviewed stated that have gone over the discipline policy and will have additional training on 9/8/23.


facility_name: Paloma Place, LLC

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: Staff member did not respond properly when youth-in-care requested alone time to speak.


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

raw_content: The operation did not have all active child records immediately available for review and reproduction at the time of inspection.


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: Hand-washing sinks for Quad 4 and Quad 2 were not equipped with soap at the time of inspection.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: Medication errors were not completed within 24 hours, as they were dated using a date range.

Correction Narrative:
Operation is no longer operating since 7/5/23, follow up cannot be completed.

Email received from director 5/12/22: All medication errors are documented appropriately on our medication error form and MAR.


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

raw_content: Medication logs did not include names and signatures of those who administered daily medication.

Correction Narrative:
Operation is no longer operating since 7/5/23, follow up cannot be completed.

2nd email received from director 5/15/23: Updated MARS to include space for staff signatures.
Email received from director on 5/12/23: Staff supervisors will document that they checked the MARS prior to coming off shift.


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

raw_content: There were 3 children that had several missed doses of medication on multiple occasions.

Correction Narrative:
Operation is no longer operating since 7/5/23, follow up cannot be completed.

2nd email received from director on 5/15/23: chart used to ensure medication refills are being done in a timely manner.
email received from director 5/12/23: When medication counts reach the last 10 doses the prescriber's office will be notified or the pharmacy if the medication can be refilled. A follow up request will be made at 5 days if the medication is not filled by that time.


raw_content: Child's medical records showed that medication was not issued according to physicans orders.

Correction Narrative:
Follow-up inspection was conducted on 5/2/23 and action plan submitted was found to be implemented.  There were no concerns at this follow-up.
Action plan received from admin: A PRN medication log has been created and will be placed in the medication log which will track when PRN medication was given and the reason for it. Shift supervisors will be responsible for the notations.


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

raw_content: Two of six beds on a pod were observed with no mattress covers or protectors.


summary: 748.3365(c)(3) - Bedding-must provide each child with clean bed linens once a week or as needed for cleanliness; linens changed/laundered if used by different child

raw_content: Several pillows were observed to be stained and dirty.


summary: 748.125(d)(6) - Suicide Screening- Must be documented.

raw_content: Suicide screening was not conducted on new admission.


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

raw_content: 2 out of 3 child's files received were not signed.

Standard Risk Level: Low

Correction Narrative:
Response from administrator: PLSP have a checklist for signatures required prior to placing the file in the chart.
Insp# 3938910 was conducted on 4/5/23.  The child record audit was created to ensure that all required signatures are being done.  I spoke to case manager which showed me all the  different worksheets that are being implemented to ensure that all signatures and documents are being completed.  She stated that the child record audit is ultimately the final record to ensure everything is being completed.


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

raw_content: In reviewing employees files, one employee did not have a current drug test completed before having contact with youth in care.

Correction Narrative:
All employees who separate from the company for any reason for any length of time will be required to take and pass a drug test prior to having contact with youth in care.
A copy of employee's drug test was emailed and uploaded on sharepoint.


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

raw_content: Two Serious Incident Reports depicting two different incidents on different dates, have the same wording verbatim. The reports were documented by different staff

Category: Organization and Administration

Correction Narrative: On 10-11-22 the administrator submitted a response to address the citation. All incident reports will be reviewed by training a compliance personnel and a training will be done with all staff on 10/11/22 and 10/12/22. The training will relay the importance of documenting each serious incident event individually. As well as always completing the incident reports in a manner that only reflects the behaviors that occurred on the day of the event being documented.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: A contracted employee who provided therapy to youth in care,  did not have a Tuberculosis Test

Category: Personnel

Correction Narrative: On 10-11-22 The administrator submitted a CAP via email, in response to the citation, which is that all contractors who provide clinical services to the residents will be asked to show proof of negative TB test.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: Two of Five medication blister packs were found to be inacurate according to the medication log.

Category: Medication

Correction Narrative: On 10-11-22 the administrator submitted a response for the citation. All medication dispensing staff members will receive training on 10/12/22 regarding accurate count reporting and legibility of MARS information.


raw_content: Serious incident report did not give an accurate account of what occurred regarding a restraint. Statements made by staff do not align with documentation in the report.

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

Correction Narrative: On 12-28-22 for an inspection, the administrator submitted a response to the citation issued. A training occurred on 10-28-22 regarding incident report writing and the importance of accuracy.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: Operation staff did not conduct an approved type of restraint on a child in care, when using a bear hug hold and walking restraint.

Correction Narrative:
On 11-04-22 the administrator submitted a response to the citation issued. Only approved restraints that are a part of CPI and Paloma Place Policy shall be used during EBI's. All guidelines set forth in the updated incident reports are to be followed. Trainings took place on 11-3-22 and 11-04-22.
On 4/13/23 follow-up insp#3940067 was conducted.  Interviews with staff and youth in care were conducted and no concerns were found over EBI.


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: A child in care was not displaying behaviors that required emergency intervention at the time of implementing the intervention or during continued interventions.

Correction Narrative:
On 11-04-22 the administrator submitted a response to the citation issued. Staff members will receive EBI refresher training in order to ensure that the child is a harm to himself or to others before a restraint may be performed. Trainings took place on 11-3-22 and 11-04-22.

On 4/13/23, follow-up inspection #3940067 was conducted.  Interviews were conducted with staff and youth in care, no concerns were noted.


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

raw_content: A child in care was restrained in order to comply with directives, to surrender a prohibited item (cell phone), and enter the operation.

Correction Narrative: On 12/28/22 A inspection was done and the administrator submitted a response to the citation issued. Staff members will receive EBI refresher training in order to ensure that proper reasoning and use of restraints aligns with the guidelines of CPI and Paloma Place Policy. The trainings took place on 11-3-22 and 11-04-22.


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: A child in care sustained a self-inflicted laceration to the head and injury to the hand.  Emergency medical treatment was obtained for the child on 8/24/2022.  The incident was not reported to Licensing as required.

Correction Narrative:
Inspection#3921782: During an interview with staff, it was stated that children are monitored 15-30 minutes after an injury occurs which at that time will be determined if the child needs medical attention.  It was stated that an SIR will be completed and a section was added to the SIR for notifications to ensure that the incident is reported to Licensing.

Email Received from Administrator: Any substantial injury that requires medical attention will be reported no later than 24 hours after its occurrence.


summary: 748.2857(b) - A copy of the documentation provided to the parent must be maintained in the childs record.

raw_content: There was no documentation found in the child's file stating the child's parent was notified of an EBI.

Standard Risk Level: Medium Low


summary: 748.2855(a)(8) - EBI Documentation-Must include the name of the person(s) who observed the child

raw_content: The Incident Report did not include information on who observed the child after the restraint and after PRN medication was provided.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: A caregiver not trained in EBI was included in the implementation of a restraint of a child in care.

Correction Narrative:
Inspection#3921782: A list of EBI trained staff members was seen posted in the staff office in the quads.

Email from admin: A list of EBI trained staff members will be posted in the staff office as an advisory of who the shift supervisor can utilize during a physical crisis. The list will be located in the staff office in the quads. A copy of that list will be uploaded into the digital drive.


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

raw_content: An untrained caregiver used a restraint hold where a child's arm was placed behind their back while held against a wall.


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: Staff member left children under his care/ratio without direct supervision to assist with a restraint.

Correction Narrative:
Inspection#3921782: During interview with staff, it was stated that administration explained to them the procedures needed to ensure they are in always in ratio.  Staff stated that they are to always have a radio on them and there is a protocol of calling the supervisor in charge first and if additional help is needed, the supervisor will call for more staff.

Email from admin: Administrator explained that staff members will be called, and they will also be extra staff members to assist with supervision when needed.


summary: 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

raw_content: The Incident Report did not list all witnesses present during a restraint.


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

raw_content: The initial Service Plan did not indicate who reviewed the plan with the youth in care and only the child's signature was obtained. It is important all team members provide signatures as required no later than the 15 days after the set date of the meeting to comply with minimum standards.

Correction Narrative:
The operation submitted a Corrective Action Plan. All service plan correspondence with DFPS will be tracked and multiple attempts will be noted and attached to service plan sections of the chart when signatures are not being pen and inked in person by the youth's DFPS worker.

The Corrective Action Plan will be found in the digital drive.


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

raw_content: During a walk-through of the operation a bed being used by one of the clients was found to be missing a mattress protector.

Correction Narrative: On 8/1/22 the Administrator sent a CAP via email in response to the citation. All mattresses are now inspected as a part of the daily environmental inspections completed by staff supervisors. In addition a copy of an Amazon order for a supply of mattress protectors were provided.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: During a walk-through of the operation the kitchen area was observed. In the refrigerator there was  a package of Hash browns that was opened, it was not properly covered.

Correction Narrative: On 8/1/22 the Administrator submitted a CAP in response to the citation. All food handlers have been directed to ensure that all food is stored in a matter that aligns with the local health department's best practices and requirements.


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

raw_content: There is information to support staff use profane language around and towards children in care.

Correction Narrative:
On 7/20/22 the administrator submitted a correction plan.  All staff have been informed of the citation and reminded to use appropriate language. Profane language towards a resident will resort in the employee being suspended or terminated.
12/8/22 - in-person follow-up was conducted.  Inspector received copy of sign-in sheet for training that was conducted with staff.


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

raw_content: In reviewing menus going back 90 days, food substitutions were not documented on the menus.

Category: Child Care

Correction Narrative: On 6/20/22 The administrator forwarded an email with a Correction plan to address the citation and bring the operation into compliance. Moving forward menus will have meal substitutes indicated on the daily menu calendar.


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

raw_content: In 1 of 4 child records, it was found that a Medication Administration Record did not have the time the medication was administered for 5 of 31 days in May 2022.

Correction Narrative: On 6/20/22 The administrator forwarded an email with a Correction plan to address the citation and bring the operation into compliance. Moving forward the Shift supervisor will inspect the MARS daily. The medication dispensing supervisor will inspect the MARS on a weekly basis and the Clinical Director will inspect the MARS on a Monthly basis to ensure accuracy.


summary: 748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP

raw_content: During a monitoring inspection a child in care was observed using a land line phone in the presence of two other children and one staff. The phone was located in a day room area were other children were watching TV. This did not allow for the child to have privacy.

Correction Narrative:
The Administrator provided their action plan in response to the citation.
Staff members have been instructed to clear out the common area of other residents during phone calls and alternatively use the staff office as a location to make phone calls during non-prescribed phone call times. A meeting was also held with staff and a signature page was forwarded as proof.


summary: 748.535(3)(F) - Child-care administrator responsibilities-Ensuring that operation complies with applicable rules of chapter 748 and other applicable rules and laws.

raw_content: The Administrator allowed a governing body member with restricted access to child file to be included in email communications regarding a child behaviors and information included in a child's record.

Correction Narrative: On 6/21/22 the Administrator submitted an action plan. All staff members have been instructed to not send any correspondence to Montray Johnson regarding information about the residents of Paloma Place RTC. The direction was given via email to all staff.


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

raw_content: During the monitoring inspection 2 of 4 Serious Incident Reports were found to be missing full names for the staff.

Category: Reports and Record Keeping

Correction Narrative: The Administrator sent an email describing how they operation has addressed the citation. An email was sent to staff advising of the change to the SIR form. The staff were informed that full names are to be documented to identify the individuals involved in the incident.


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: 13 year old child in care was slapped by a caregiver and a 14 year old child was grabbed by the throat and slammed to the floor by the same caregiver.

Correction Narrative: On 5/10/22 the Administrator forwarded an action plan to address the violation: A staff meeting and training session has been scheduled for all staff members both administrative and direct care for 05/10/22 and 05/13/22. Paloma Place policies and procedures will be discussed, and an understanding of trauma informed care will be presented as well. On 05/09/22 all staff members on duty reviewed the policy on discipline and signed an acknowledgement form. All sign in sheets will be made available to inspectors. Form 7266 was sent out on 05/09/22 to all of the resident's guardians.


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

raw_content: Permit holder told a child in care to not participate in interviews with investigators.  The child did not participate in two interview attempts.

Correction Narrative: On 5/10/22 the Administrator forwarded via email an action plan to address the violation. A staff meeting and training session has been scheduled for all staff members both administrative and direct care for 05/10/22 and 05/13/22. Investigation cooperation will be discussed. A section regarding investigation cooperation will be added to the Paloma Place employee handbook and policies and procedures. All employees and residents are going to be encouraged to speak in a truthful manner when talking to investigators from any agency. All sign in sheets will be made available to inspectors.


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

raw_content:
During a walk through of the operation, two first aid kits were found to be missing items. one kit was missing a thermometer and the other a pair of scissors.
NOTE:  No Action plan is required, the Deficiency was corrected at inspection.


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

raw_content: During a walk through of the operation. It was noticed that that several 2X2 railings were missing from a wooden stairway  leading to the recreational area.


summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: During a walk through of the operation it was observed that an  emergency evacuation and relocation diagram was not posted in a prominent and visible location.


summary: 748.989(a) - Documentation of first-aid and CPR certification-Document completion of each training requirement in the appropriate personnel records

raw_content: During a review of  records it was found that a caregiver was missing CPR Certification and First Aid Certification documentation in the personnel file. A second caregiver was missing First Aid Certification documentation in their personnel file.

Category: Training and Professional Development

Correction Narrative: Program Manager,submitted a Corrective Action Plan to address the citation: Employee files reviewed have been updated to include staff current CPR/First Aid certification. An audit of employee files will be conducted by training staff regularly to ensure that training is in staff files in a timely manner. The documents have been uploaded in the digital storage.


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

raw_content: During a review of personnel records a caregivers affidavit for employment was incomplete.

Correction Narrative:
Program Manager submitted a Corrective Action Plan to address the citation:  A discussion has been held with the notary explaining that affidavits must be completed in their entirety prior to receiving her stamp of approval. An audit of employee files will be completed by staff to ensure all documents in employee files are completed.
A copy of the corrected 2985 was also provided. The documents have been uploaded to digital storage.


facility_name: Pinecrest Emergency Care Services

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

raw_content: One of the children's medication log was missing the time, name, and signature of the staff who administered the medication.

Correction Narrative:
1.Process for Ensuring Complete and Accurate MARs:
Standardized MAR Template: Pinecrest uses a standardized Medication Administration Record (MAR) that includes mandatory fields: medication name, dosage, time of administration, staff initials, staff signature, and running pill count. The form cannot be submitted if fields are left blank.
Staff Training & Competency Testing: All staff responsible for administering medication undergo hands-on MAR training and a competency exam requiring 100% accuracy in recording dosages, signatures, counts, and times. They must demonstrate proper completion of both MAR and Medication Error Reports during testing.
Medication Error Reporting: The Medication Error Log and Reporting Protocol is in place. Every missed, late, or undocumented dose must be reported on the MER form, signed by the staff, and reviewed by the Health Liaison. Reports are filed in the child's record and logged electronically for tracking.
Assurance of Prescribed Administration: Only trained staff are permitted to administer medications. Staff designated to administer medication may not be placed in ratio until training and competency testing are documented. Additionally, medication sheets are cross-checked daily to ensure all medications are dispensed exactly as prescribed.


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

raw_content: One of the staff's TIC training was taken on 2/1/2024 then again on 7/23/2025. The training was taken 5 months late.

Correction Narrative: 2.	Staff cannot count toward ratio until they complete all mandatory training. This ensures only fully compliant staff are supervising children, protecting youth safety and ensuring regulatory adherence.


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

raw_content: A caregiver failed to show competency and prudent judgment when video recording a child exhibiting escalated behaviors and engaging in property destruction.  The footage was captured on the caregivers cell phone and shared with another employee.  While recording the event, the caregiver failed to preserve the childs privacy, was unable to intervene for the safety of the children in care, and failed to maintain the facility.

Correction Narrative: Staff and children were interviewed during the inspection with no concerns noted.


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

raw_content: A designated spot to shelter in place was not indicated on the evacuation diagram for the operation.

Correction Narrative: An email was received from the operation's administrator which included an updated evacuation diagram for the operation to include a designated shelter in place location.


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

raw_content: During the walkthrough of the facility, evidence of water leak was observed in the kitchen and resident room ceiling.


summary: 748.3353(b)(1) - Monitoring Devices-Parent, or other person legally authorized to consent, must consent to the use of the video camera

raw_content: During the walkthrough of the facility, one battery operated camera was observed mounted on the wall in the children's restroom (lobby). Staff was not able to provide inspector with written approval from CVS caseworker or any approved waiver to use camera in children restroom area.


summary: 748.941(c)(3)(B) - Training Criteria-Training must require each participant to demonstrate the physical EBI techniques, if the GRO allows the use of EBI.

raw_content: Five employees of the operation completed a different EBI curriculum than what's utilized at the operation evidenced by training certificates reviewed.

Correction Narrative: An email was received from the administrator that included a corrective action plan indicating the employees have all taken the CPI EBI training to be compatible with other employees. The email also included verification of the completed trainings. On August 23, 2024, an email was received from the operation's administrator which included a safety plan for the employees who were missing the same EBI training until they were able to complete the training.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: One of three employee files reviewed did not contain documentation of the reference checks completed on the employee.

Correction Narrative: An email was received from the administrator with a copy of the verification of the missing reference checks for an employee.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content: This standard was reviewed and the Operation is deemed to be not in compliance hereof.

Correction Narrative: The operation e-mailed a statement saying the staff member in question is currently not employed at the operation pending an Administrative Review for their RTB finding.


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

raw_content: One staff file reviewed did not have a current normalcy training.

Correction Narrative: The operation sent documentation of the staff members completed normalcy training.


summary: 748.911(b)(3)(B) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi or Adult CPR if serving children 0 to 17.

raw_content: One staff file reviewed did not have a current CPR/First aid training.

Correction Narrative: The operation sent documentation of the staff members completed CPR/First Aid training.


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

raw_content: During the course of this investigation, it was determined that the safety and well-being of the child was compromised in contravention to the provisions of the child's Safety Plan.

Correction Narrative: The operation sent the following statement in regards to the citation: All Pinecrest direct care staff will continue to supervise children in care according to Minimum Standards and according to the Safety Plan of children in care. The owner/Administrator also stated in a phone conversation that he did not have a Safety Plan for the child in question.


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

raw_content: The menu was observed to be outdated in addition there were no snacks or food sustitutions on the menu.

Correction Narrative: The operations menu was updated to meet minimum standards. A copy of the updated menu was e-mailed.


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: One of the dressers in a child's bedroom was observed to be broken, it was missing a knob and had a protruding nail in addition the first drawer was broken and was missing the part of the drawer that is needed to hold the child's clothing in it.

Correction Narrative: The operation sent pictures of the dresser in question. It had been repaired to meet minimum standards.


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: During the course of this investigation, it was determined that staff utilizes restraints for non emergency situations such as kids cursing staff or not listening to staff.

Correction Narrative: Five out of five children interviewed on 12/06/2023 stated they have not been restrained since being placed at the operation nor have they witnessed a restraint. The operation stated every staff member was retrained in EBI and documentation was e-mailed along with the statement for proof.


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

raw_content: The caregivers involved in the EBI did not conduct a post discussion with the child after the EBI.

Correction Narrative:
In response to the deficiencies found in investigation # 3029843, Pinecrest has retrained staff on Emergency Behavior Intervention according to Minimum Standards  General Residential Operations. Please accept the attachments as proof of completed training.
On 12/06/2023, five residents were interviewed and stated they have never been restrained since being placed at the operation and have not witnessed a restraint since being placed at the operation.


summary: 748.2551(f) - EBI Implementation-If child doesn't understand what to do to be released, caregiver re-explains every 15 minutes until child understands or released

raw_content: The caregivers did not explain to the child what they needed to do to be released from the EBI.


summary: 748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.

raw_content: A child in care was restrained longer than 30 minutes.


summary: 748.3441(d) - Food Preparation-Must only use disposable, single-use items if the operation lacks adequate facilities for sanitizing dishes and utensils

raw_content: During the inspection cups with children names were in the kitchen after being used and not disposed.


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

raw_content: During an after hours visit at the operation, the medicine cabinet was observed to be unlocked.

Correction Narrative: The operation sent a Corrective Action Plan which stated the following: The licensed childcare administrator and/or designee will train all administrative and direct care staff on the minimum standards and Pinecrest's Operation Manual regarding medication storage to prevent children from gaining access to and ingesting medication by themselves. An in person follow-up inspection was conducted on 12/12/2022. A picture was taken of the operations new medication storage cabinet and uploaded to the digital storage.


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

raw_content: Operation was not in compliance with a child's supervision requirements.

Correction Narrative: The operation sent a Corrective Action Plan which stated the following: The licensed childcare administrator and/or designee will train all administrative and direct care staff on the minimum standards and Pinecrest's Operation Manual regarding the caregiver's responsibility of providing the level of supervision necessary to ensure a child's safety and well-being. An in person follow-up was conducted on 12/12/2022. Children were interviewed in regards to child/caregiver ratio and supervision. There were no concerns.


summary: 748.1009(2) - Child/caregiver ratio-Must employ adequate number of caregivers to meet their responsibilities regarding supervision of children in 748.685

raw_content: Supervision needs for the group of children required a closer supervision for more than 3 of the children. Specifically one child had a service plan which required a 1:5 ratio while sleeping. There were two other children whose ratio should have been elevated based on their history.

Correction Narrative: The operation sent a Corrective Action Plan which stated the following: The licensed childcare administrator and/or designee will train all administration and direct care staff on the ideology and implementation of Child/Caregiver ratio outlined in both in Minimum Standards and Pinecrest's Operations Manual. Pinecrest will employ an adequate number of caregivers to meet their responsibilities regarding supervision of children in care. An in person follow-up was conducted on 12/12/2022. Children were interviewed in regards to child/caregiver ratio and supervision. There were no concerns.


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

raw_content: A caregiver failed to inform the administration that his co-worker left the operation during the shift and that he was working alone. Another caregiver failed to inform the administration that he was leaving his shift early.

Correction Narrative: The operation sent a Corrective Action Plan which stated the following: The licensed childcare administrator and/or designee will train all administrative and direct care staff on the policy and procedures for absenteeism and tardiness. The licensed childcare administrator and/or designee will retrain staff on the importance of demonstrating competency, prudent judgement, self-control, in the presence of children and when performing assigned tasks.


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

raw_content: 1 of out 8 medication records was not updated with the amount administered within 2 hours.

Correction Narrative: This standard has been reviewed and is compliant.


summary: 748.3117(b) - Fire Extinguisher-Must keep documentation of annual inspection and/or purchase of new fire extinguishers at operation for review

raw_content: During the walk through it was observed that the South hallway exit door did not have a verified inspection tag for the fire extinguisher hanging (photos taken).

Correction Narrative: A new fire extinguisher was purchased and a picture of both the fire extinguisher and receipt were e-mailed. The last fire inspection was conducted on 06/28/2021.


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 four child files reviewed did not contain a TB test.

Correction Narrative: A copy of the child's TB test results were e-mailed.


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

raw_content: One discharged child's file did not include the circumstances for the discharge.

Category: Admission, Service Planning, Discharge

Correction Narrative: An updated discharge form was e-mailed, which contains all required information.


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

raw_content: One discharged child's file did not contain name, address, telephone number, and relationship of person to whom the child was discharged to.


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

raw_content: Two staff files reviewed did not contain a statement signed and dated by the employee confirming they have read a copy of the operational policies.

Correction Narrative: The administrator e-mailed a signed and dated document which states the staff members have read the facilities operational policies.


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

raw_content: Two staff files reviewed did not contain a signed and dated statement by the employee that he/she must immediately report suspected abuse, neglect or exploitation.

Correction Narrative: The administrator e-mailed a copy of a document signed and dated by the employees which states they will report suspected abuse/neglect or exploitation.


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

raw_content: One staff file reviewed did not contain a high school diploma.

Correction Narrative: The administrator e-mailed a copy of the staff members high school diploma


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: One staff file reviewed did not contain a copy of a cleared tuberculosis screening.

Correction Narrative: The administrator e-mailed the staff members negative TB test.


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

raw_content: Two staff files reviewed did not contain a current job description.

Correction Narrative: I was e-mailed a copy of two staff members job descriptions that will be placed in their files.


facility_name: Girls Haven

summary: 748.3441(p) - Food Preparation-Must maintain hot food at 140 degrees Fahrenheit or above

raw_content: The operation had 11 prepared individual food plates stored on the countertop covered with plastic wrap at 2:43PM with the intention to reheat and serve the food for dinner at 5PM.

Correction Narrative: An email received from the administrator on 03/05/26 had the following attached plan of correction: Operation will ensure all food is properly maintained and stored before serving if kitchen staff is going to be out by communicating the task to a staff on duty.


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

raw_content: The operations' emergency relocation map does not show shelter in place designation. The administrator reprinted the relocation map wth the shelter in place location.


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

raw_content: Thermometers were not observed in the two refrigerators of the kitchen or three freezers. Maintenance staff corrected by placement of thermometers in the two refrigerators and three freezers.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: A caregiver's Emergency Behavior Intervention training was not renewed timely.

Correction Narrative:
A second email received the administrator on 12/12/25 identified additional details for the plan of correction: the EBI training will be included in the operation's training file audit conducted every three months by the ED and Residential Supervisor. Additionally, trainings will be scheduled enough in advance to ensure deadlines are met.
A plan of correction received by email from the administrator on 12/02/25 identified the following: Operation will ensure that all EBI training is renewed before the 6-month date of the previous training. The staff in question completed the EBI training but it was 17 days after the 6-month time frame.


summary: 748.463(a) - Unauthorized Absence Evaluation - Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period

raw_content: During a monitoring inspection, the operation was unaware of an evaluation that addressed the unauthorized absences.

Correction Narrative: In an email received from the administrator on 08/26/25 the following corrective action plan was attached with the plan for findings: Girls Haven has completed the unauthorized absence evaluation and will continue to update every 6 months. A copy of the evaluation was received in a separate email.


summary: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

raw_content: The fire inspection conducted identified areas of concern that needed correction.

Correction Narrative: A corrective action plan was received via email from the administrator on 08/21/25. The plan identified the following: GH will ensure all areas of concern are corrected in a timely manner and future inspections will be done separately from the Ehrhart School to ensure proper inspection and report scores. A copy of the completed and corrected fire inspection was received from the operation by email on 09/02/25 from the administrator.


summary: 748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them

raw_content:
RCM completed an HM visit at Girls Haven on 05/14/2025 RCM observed a youths hair to remain in dry, flaky, brittle, and unmanaged.  Her hair was observed to be dry, flaky brittle and unmanaged during the visit on 04/30/2025, at which the administrator stated she would ensure the youth receive proper hair treatment.  During the visit on 04/30/2025, RCM spoke with the youth regarding her hair treatment. The youth stated she previously had braids but took them down after a few weeks because her scalp was itching and flaking.  She was informed by staff she could not get braids again because she took them down to soon.
On 05/14/2025 RCM spoke with the same youth regarding her hair care. Youth reported she blow dries her hair in the morning. When asked why she blow dries her hair when its already dry, youth stated she wants it to be strait.  RCM advised she needs to moisturize her hair daily to prevent it from breaking. Youth stated her sister (also placed at the facility) was going to braid her hair. Its important to note other youth (of African American decent) hair was also observed to be dry and in need of treatment.

Correction Narrative: On 06/04/25, an email received from the administrator identified the following plan of correction: The youth in question along with 5 other youth have had hair appointments since 5/14/25 and had their hair cut and/or braided. Girls' Haven will continue to hand out appropriate hair products and will document when each girl is provided with items. Administrator will schedule training on hair care for the residents.


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: During an inspection, the service plan for a child was not signed by the case manager.


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

raw_content: During an inspection, an employee no longer with the operation remained active on the people list.


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: During an inspection, a personnel record did not contain evidence of two reference checks completed.

Correction Narrative:
On 05/21/25 an email with the following plan of correction was received from the administrator: Girls Haven will ensure all new hire files have documented record of references being contacted to verify the applicant is suitable to work around children. Residential Supervisor and Executive Director will continue to audit and maintain all personnel files for this information.
On 05/19/25, an email was sent to the administrator with a reminder to send the plan of correction that was due on 05/14/25.


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

raw_content: A child's unauthorized absence was not reported to licensing within 6 hours.

Correction Narrative: On 5/12/25 corrections were received via email. The agency's Administrator will either make the report or delegate the report to an on-shift supervisor after reviewing the reporting time expectations in standards.


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 14, 2025, it was determined that:

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

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

As you know, the heightened monitoring plan 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 plan, 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.

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 plan.

An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human
Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open
investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32.

Correction Narrative: An HM extension was approved effective 3/16/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your 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 9/15/2025.


raw_content: A staff EBI SAMA training certificate was expired.

Standard Number / Description: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

Correction Narrative: A corrective action was received from the operation's administrator on 04/01/2025 stating an EBI training was conducted on 03/30/2025 and 03/31/2025. A training certificate was received for the staff that had the expired training certificate.


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

raw_content: During an investigation, several children in care indicated that staff were loud with them or had yelled at them.

Correction Narrative:
In an email received from the administrator on 02/14/25 an attachment contained the corrective action plan. The plan for findings includes the following: All staff will attend a meeting/training to review (agency) policy along with TBRI program as a reminder of proper discipline and de-escalation.
2/26 a physical follow up was conducted with HM Inspection 4044696. A shift supervisor and the administrator were interviewed regarding supervision, ratio, meds, and discipline. No concerns. Due to new staff onboarding, the training to review policy has not been completed yet, upon completion a sign in sheet of attendance will be submitted to Licensing.


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

raw_content: During an investigation, several children in care indicated they had been hit on the hand by a staff for trying to change the radio or turn the volume up.  Other children in care witnesses this occurring.

Correction Narrative:
An email received on 02/14/25 from the operation's administrator identified the following corrective action plan: The alleged staff has already been met with regarding proper discipline and de-escalation. A sign has been placed in the transport van stating that no residents should touch the radio and the rules for what age can sit in the front seat. All staff will attend a meeting/training to review (agency) policy along with TBRI program as a reminder of proper discipline and de-escalation.
2/26 a physical follow up was conducted with HM Inspection 4044696. A shift supervisor and the administrator was interviewed regarding supervision, ratio, meds, and discipline. No concerns. Due to new staff onboarding, the training to review policy has not been completed yet, upon completion a sign in sheet of attendance will be submitted to Licensing. The sign was observed by HM, and photos taken and available in the document library.
Follow up completed on 03/11/25 obtained a copy of the sign-in sheet for staff training on Policies, Procedures, and Behavior De-escalation dated 03/07/25. There are four staff signatures on the sign-in sheet along with the administrator. Administrator stated the operation has been slowly retraining staff but due to staff shortages it has taken longer.


raw_content:
 During a review conducted on September 9, 2024, it was determined that:

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

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

As you know, the heightened monitoring plan 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 plan, 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.

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 plan.

An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32.

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 9/10/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your 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 3/10/2025.


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 investigation, it was discovered that a caregiver fell asleep on an evening shift.

Correction Narrative:
 The staff that was alleged to be asleep is no longer employed by Girls' Haven. The remaining staff all participated in
a staff meeting regarding the 24 hours awake supervision policy and signed acknowledgments. As part of a
compliance plan, we also have policies in place which includes administrative staff doing random check ins of both the facility and cameras.

An in-person inspection was conducted on 06/04/2024 (Inspection #4004656), where nighttime supervision was discussed. The operation stated that they were frustrated that they were not aware of the incident when it occurred, however regulatory was made aware of the incident after it happened. The operation stated that they have a roster of night-employees that they feel confident in currently.


raw_content:
During a review conducted on March 7, 2024, it was determined that:

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

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

As you know, the heightened monitoring plan 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 plan, 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.

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 plan.

Correction Narrative: An HM extension was approved effective 3/8/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your 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 9/8/2024.


raw_content: A staff member at the operation was not providing adequate supervision to children in care due to the staff sleeping.

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:
An corrective action was received from the operation's administrator on 02/27/2023 stating the following:  Girls' Haven will conduct an inside investigation on the alleged staff and then take proper action with either a written warning and/or employee termination. We will also conduct a staff meeting and training to ensure all night staff are aware and willing to comply with staying awake and see if there are any suggestions on what we can offer in assistance.
An inspection was conducted on 02/27/2024 by the assigned inspector, two staff and the administrator were interviewed. Both staff denied sleeping and the administrator provided a corrective action plan.

A follow-up email was sent from RCCR staff to the operation's administrator on 02/29/2024 requesting the date of the internal investigation and the staff training/staff meeting.
The assigned inspector stated he will be reviewing the training documentation sign-in sheet when the next inspection is conducted.

On 03/11/2024, I, Andrew Ward conducted an inspection in which training documentation from the plan of correction was reviewed. No concerns.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: Med logs were reviewed during a heightened monitoring contracts inspection on 11/1/2023 for youth D.M. During the review of the medication log and medication, RCM observed the medication count for AM Risperidone did not correspond with medication log. According to the medication log there were 2 tablets for Risperidone remaining on the AM log; however, there was only one pill remaining.

Correction Narrative:
Compliance was established through a physical-inspection. Inspection #3977093 was conducted on 11/20/2023. Six children's medication logs were reviewed alongside an actual count of children's medications. No medication errors, miscounts, or other discrepancies were observed.

Written Compliance was received on 11/22/2023. The employee was retrained on policies and procedures for Medication Administration.


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

raw_content: Four of four child's records do not address the child's specific needs for supervision.

Correction Narrative: Girls' Haven staff (executive director and case manager) will review the current minimum standards and update our current admission assessment and service plans to meet the standards and ensure all appointments and information are updated in a timely manner.


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

raw_content: A child's record contains inconsistent information regarding the child's admission date on the ISP and 72Hr. Another child's record has conflicting information regarding the recreational and normalcy activities.


summary: 748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs

raw_content:
Four of four reviewed 72 hour plans do not address the following information:
b) In addition, for a child receiving treatment services the preliminary service plan must include:
(2) A description of the childs immediate educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child
(3) A description of how you will meet the childs needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child
(4) The identification of any issues or concerns the child may have that could escalate a childs behavior. Identification of a childs issues or concerns must serve to avoid the use of unnecessary emergency behavior interventions with the child. Child concerns may include issues with food, eye contact, physical touch, personal property, or certain topics

Correction Narrative: Girls' Haven staff (executive director and case manager) will review the current minimum standards and update our current admission assessment and service plans to meet the standards and ensure all appointments and information are updated in a timely manner. The operation provided an update Admission Assessment form that meets the requirements established by Minimum Standards.


summary: 748.1217(c)(7) - Admission Assessment-Prior to initial service plan, add child's history of other placements (admission and discharge dates, reasons for placement)

raw_content:
The following information was not added to four of four reviewed records, prior to the ISP being conducted:
(3) The childs birth and neonatal history
(4) The childs developmental history
(5) The childs mental health and substance abuse history
(6) The childs school history, including the names of previous schools attended and the dates the schools were attended, grades earned, and special achievements
(7) The childs history of any other placements outside the childs home, including the admission and discharge dates and reasons for placement
(8) The childs criminal history
(9) The childs skills and special interests


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

raw_content:
Four of four reviewed child files were missing information regarding:
(3) A description of the childs behavior, including appropriate and maladaptive behavior, and any high-risk behavior
(4) Any history of physical, sexual, or emotional abuse or neglect
(5) Any history of trauma
(6) Current medical and dental status, including the available results of any medical and dental examinations
(7) Current substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment
(9) The childs current educational level and any school problems
(15) The childs understanding of the placement
(16) A determination of whether and how you can meet the needs of the child

Correction Narrative:
Girls' Haven staff (executive director and case manager) will review the current minimum standards and update our current admission assessment and service plans to meet the standards and ensure all appointments and information are updated in a timely manner.
The operation provided an update Admission Assessment form that meets the requirements established by Minimum Standards.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: A child's record did not document when their dental appointment was scheduled or if the child has had a dental examination within the past year.


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

raw_content: Four of four child records do not include whether or not a child has a chronic illness. Including a child that has asthma.


summary: 748.1221(a) - Admission Assessment-Must make reasonable efforts to obtain all required information

raw_content: Four of four reviewed records did not document the operation's efforts to obtain information missing in order to complete the child's record.


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

raw_content: Four of four records do not document an assessment of the child's information to evaluate the appropriateness of placement.


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

raw_content: Four of four child records did not address the known contraindications to the use of restraints.


raw_content:
During a review conducted on September 5, 2023, it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.

Correction Narrative: An HM extension was approved effective 9/5/23. In conjunction with this extension, a new deadline was established by which all requirements must be completed by your 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 March 6, 2023.


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

raw_content: No written plan for indoor and outdoor recreation was available for review during inspection.

Category: Recreation Activities

Correction Narrative: The Administrator provided 2 weekly calendars of indoor and outdoor activities that will be rotated.


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

raw_content: 2016 Ford Transit 350 used to transport children in care indicated needing an oil change. Oil change was conducted/completed during inspection at the operation.

Category: Transportation


summary: 748.3273(2) - First Aid Kits-Each one must contain adhesive tape

raw_content: First Aid Kit was observed without adhesive tape and thermometer. Items were placed in the First Aid Kit prior to exiting the inspection.


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

raw_content: Based on information gathered during an evaluation of the operation's records, it was found a child's record contained inaccurate documentation as related to a document in the child's record.

Correction Narrative: 08/23/2023-Girls Haven LCCA submitted licensing staff a revised copy of the operation's Corrective Action Plan stating Girls Haven will ensure records and documentation are accurate, documented correctly, and maintained.  The Clinical Team will continue to review and audit the resident binders on a monthly basis.


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

raw_content: 1 of 9 employee files did not contain the pre-employment drug testing results.

Correction Narrative: An email was sent to rccr staff on 03/14/2023 from the operation staff of the staff's completed drug testing results.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: 4 of 4 volunteers records was observed to be missing the TB screening/results.

Correction Narrative: An email was sent to rccr staff on 03/14/2023 from the executive director of one of the active volunteer's tb test results. The executive director sent an email stating two of the volunteers were inactivated out of their system and stated the other volunteers have been informed a tb test would be required before coming back to the operation.


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 2/28/2023 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.

The heightened monitoring plans for this operation included a specific planned end date at the 12-month mark by which the 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, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
- Operation was unable to meet compliance with Medium-High weighted citations.

Correction Narrative: An HM extension was approved effective 2/28/23.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your 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 September 1, 2023.


summary: 748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible

raw_content: A child in care had head lice, and the operation staff failed to provide continuous care in order to ensure the head lice was no longer present.

Correction Narrative: RCCR Attempted to obtain corrective action, LCCA stated she has already sent documentation regarding the concerns/citations, and no other documentation is needed on 04/10/2023. LCCA stated an administrative review will be requested. A corrective action was sent to rccr staff on 04/19/2023 stating going forward residents will be checked daily following a lice treatment to ensure the lice is cleared.


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

raw_content: 1 of 9 staff records was observed to be missing a job description.

Correction Narrative: An email was sent to rccr staff on 03/14/2023 from the executive director of the staff's signed job description.


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

raw_content:
One staff training records reviewed was inaccurate.
A new staff members training records showed multiple online and in person trainings completed that exceeded the maximum amount of hours the employee worked. One of the training records reviewed date of training was incorrect.

Correction Narrative: RCCR Attempted to obtain corrective action, LCCA stated she has already sent documentation regarding the concerns/citations, and no other documentation is needed on 04/10/2023. LCCA stated an administrative review will be requested. A corrective action was sent to rccr staff on 04/19/2023 with the training record that showed the date to be corrected.


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

raw_content:
6 of 9 employee records reviewed contained employment affidavits that were not notarized.
1 of 9 employees records reviewed did not contain an employment affidavit.

Correction Narrative: An email was sent to rccr staff on 03/14/2023 from the executive director of the staff's notarized affidavits.


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

raw_content: A review of the PLSP's record reveals the PLSP does not meet the professional requirements for the position, only meets the education requirements. The PLSP does not meet the requirement of having 1 year full time experience in residential child care operation.

Correction Narrative: An email was sent to rccr staff on 03/24/2023 from the administrator stating the contract LPC will contract as the service provider. RCCR verified the professional qualifications for the LPC in order to ensure the contractor met the professional qualifications and determined to be in compliance.


summary: 748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development

raw_content: During a walk thru multiple foods were expired in the pantry area.

Correction Narrative: Pantry was observed to have expired food discarded. Insp #3935117


summary: 748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health

raw_content: One child annual well-child check up record instructions included a follow up visit to be conducted in two weeks for a diagnoses of an infection. The childs follow-up visit wasnt conducted.

Correction Narrative: RCCR Attempted to obtain corrective action, LCCA stated she has already sent documentation regarding the concerns/citations, and no other documentation is needed on 04/10/2023. LCCA stated an administrative review will be requested. A corrective action was sent to rccr staff on 04/19/2023 stating the child was seen in the behavioral hospital a month later for the medical issue. A supporting document/medication order summary was sent dated 03/01/2023 for the child. The corrective action stated a referral and appointment have been made for the child to see a urologist.


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

raw_content: The food menu did not have any food substitutions listed on the menu.

Correction Narrative: Follow up conducted at the operation, insp #3935117. Menus observed to be in compliance


summary: 748.1703(c) - Menus-must date menus and keep copies for 90 days

raw_content: The food menu did not have the month or the dates on the menu.


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

Correction Narrative: The child was not administered one prescription medication as it was ordered. The medication was to be provided every 8 hours, which was 3 times daily but was only given 2 times daily. The medication was prescribed on 09-06-22 and not administered/received by the operation until 09-16-22.


raw_content:
During a review conducted on 8/26/2022 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.

The heightened monitoring plans for this operation included a specific planned end date at the 12-month mark by which the 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, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:

-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Correction Narrative: An HM extension was approved effective 8/27/2022.  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 2/27/2023.


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: Room 5 had mildew on the closet ceiling.


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

raw_content: The operation's fire inspection has expired as of 03/02/2022.

Correction Narrative: Licensed Child-Care Administrator Elizabeth Milam submitted Girl's Haven Fire Inspection report via email on 07/08/2022 with completed inspection date of 07/08/2022.  According to the Fire Inspection Report, the operation was approved with no violations.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: During the inspection, a medication error was discovered. In the child's file reviewed, a medication error occurred in which the remaining medication count was 52. However, the medication log reflected 53.

Correction Narrative: All medication trained staff have been addressed on the importance of logging each medication given and maintaining a correct count. A medication error was written and placed in binder.


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

raw_content: The operation continues to be without a qualified full time Licensed Child Care Administrator. The operation's board continues efforts in the search for an Administrator.

Correction Narrative: Elizabeth Milam passed the LCCA exam and is now active licensed LCCA. Verification in CLASS Admin Lic. C14841.


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: A child fell on the return from school on 11/19/21, injuring her arm and leg, requiring medical treatment (received same day), and follow ups. The operation did not report the serious incident until 11/21/21.

Correction Narrative:
Operation submitted on 1/6/22-Corrective Action Plan for 748.303(a)(2)(A)  Girls' Haven has revisited our on-call and reporting procedures with a focus on DFPS reporting. Shift Supervisors on-duty shall be required to report all serious incidents to the on-call administrator as soon as possible and all incidents that require notifications to law enforcement and DFPS licensing shall be reported according to the required timeframes as required by minimum standards. In addition, the Executive Director shall be notified on all serious incidents; a responsibility that shall be by the primary on-call administrator. Specifically, any serious injuries shall be reported to DFFS licensing as soon as possible and by no later than 24 hours after the injury warrants treatment. All Girls' Haven shift supervisors and on-call administrators have been trained on the above-mentioned plan.
*There was a delay in receiving the corrections due to the operation sending to the incorrect email address.


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

raw_content: During the course of interviews with children in the operation, it was found that that one staff member made comments that were demeaning and negative towards their body and weight.

Correction Narrative:
A corrective action plan was submitted through email on 1/26/2022. The plan for findings is as follows: All staff have been addressed on Child Right's and appropriate conversation with residents. Additionally, on February 2nd and 3rd, 2022, all Shift Supervisors will be attending a TBRI training.

Facility's Corrective Action Plan has been uploaded to digital storage.


raw_content: The operation does not have a qualified full time Licensed Child Care Administrator.

Standard Number / Description: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator