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

raw_content: Law Enforcement was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history.

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure all staff are trained to report and document serious incidents as it relates to unauthorized absence to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. If a child is suspected of or was a trafficking victim, the unauthorized absence will be reported immediately. Training documented by certificate.


state: TX

facility_name: Blessed Kidz Residential Treatment Center, LLC

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

raw_content: The parent was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure all staff are trained to report and document serious incidents as it relates to unauthorized absence to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older. If a child is suspected of or was a trafficking victim, the unauthorized absence will be reported immediately. Training documented by certificate.


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 child, with identified trafficking history, admitted to having a sexual encounter with a person after an unauthorized absence from the operation was not taken to be seen by medical personnel.

Standard Risk Level: Medium High

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure that all staff receive training on competency, prudent judgment and self-control in the presence of children and when performing assigned tasks. Upon return from an unauthorized absence, if a child discloses that she has had sexual intercourse, a provider will be found that can assess her within a week. Training documented by certificate.


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: Licensing was not notified of a child's absence from the operation. Immediate notification is required due to the child's trafficking history.

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure all staff are trained to report and document serious incidents as it relates to unauthorized absence to licensing no later than 6 hours after determining unauthorized absence of a child 13 years old or older. If a child is suspected of or was a trafficking victim, the unauthorized absence will be reported immediately. Training documented by certificate.


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

raw_content: A child in care ran away from the operation three times in two days; the operation only had documentation for two of the three incidents.

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure all staff are trained to report and document serious incidents. Training documented by certificate.


summary: 748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the childs return.

raw_content: The serious incident report for an unauthorized absence of a child in care did not include an update upon the child's return.

Correction Narrative: On 11/6/2024, the operation's Administrator advised Blessed Kidz RTC will ensure all staff are trained to report and document serious incidents as it relates to unauthorized absences as well as updates to such reports upon their return. Training documented by certificate.


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

raw_content: The operation's former Administrator is still serving in the capacity of and identifying themself as the Administrator of the operation. The identified Administrator was not present at the operation during CCIs visits and a designee was not assigned.

Correction Narrative: On 11/6/2024, the operation's Administrator advised when the operation's administrator cannot be present, a designee will be listed to assume the daily supervision and on-site administrative responsibility of the overall operation.


raw_content: Information regarding child in care unauthorized absence was not documented the incident report.

Standard Number / Description: 748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the childs return.

Correction Narrative: Management met with staff on April 25, 2024 and discussed the importance of documenting Serious Incidence Reports in detail. The administrator will provide additional training to caregivers quarterly on the importance of updating the Serious Incident Report to fully document the incident, including, but not limited to, the date and time of absence along with when a child returns from an unauthorized absence.


facility_name: Greener Pastures RTC

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

raw_content: A staff member with conditions was left in the night ratio without proper supervision.

Standard Risk Level: High

Corrected at Inspection: Yes


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

raw_content: Reverse light to left side of vehicle was not in working order.

Category: Transportation


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: A caregiver counted in ratio during the time of a serious incident did not have any hours of EBI training.

Correction Narrative:
The staff member who was delinquent in training is no longer employed.
Effective immediately, the facility has implemented the following corrective actions:
1.	Immediate Staff Training Review
o	The Administrator conducted a full audit of all active caregiver training files to verify EBI hours completed.
2.	Immediate Compliance
o	All caregivers providing child-care or program services now complete at least 4 hours of EBI training prior to being counted in supervision ratios.
o	All caregivers providing treatment services must complete the full 16 hours of EBI training before providing treatment services.
3.	Training Completion Timeline
o	Remaining EBI hours for child-care/program staff will be completed within 90 days of hire.
o	Remaining training is tracked through a training compliance log maintained by Administration.
4.	Documentation & Tracking
o	Training certificates are now placed in each employee file immediately upon completion.
o	A master EBI Training Tracker is maintained and reviewed monthly by the Licensed Child-Care Administrator.
5.	Ongoing Prevention
o	New hire orientation now includes mandatory EBI training scheduling prior to shift assignment.
o	No caregiver will be placed on the schedule or counted in ratio without verified compliance.
o	Quarterly internal audits of training files will be conducted to ensure continued adherence.
Person Responsible
Licensed Child-Care Administrator (LCCA)
Completion Date
Immediate and ongoing compliance as of 12/8/2025


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: A child in care was detained and charged and the operation failed to report the incident to licensing..

Correction Narrative:
The operation emailed the following corrective action plan:

 All direct care staff, supervisors, and administrative personnel will receive retraining on 10/23/2025 Texas Administrative Code §748.303 and §748.313 regarding serious incident reporting requirements.

Training will emphasize timelines, documentation, and communication protocols for incidents involving law enforcement.


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

raw_content: During the inspection, it was observed that a mayonnaise was not proplery stored in the refrigerator. The mayonnaise was later thrown away.


summary: 748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: the affidaviatis for 3 employees did not have the complete information if good cause for refusal of employment.

Category: Reports and Record Keeping


summary: 748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them

raw_content: There are no evacuation plans posted to the rooms or entrance/exit areas.

Category: Organization and Administration


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: Several rooms of the operatin had markings on doors and the walls, Broken electrical coverings and  broken blind, Dirty clothes on the floor were visible in closets.


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

raw_content: Two children in care left the placement due to a lack of supervision.

Correction Narrative: Four children were interviewed regarding supervision and there were no concerns. The children expressed always being supervised when needed and that staff are always present. A corrective action plan was provided and states the following: All staff have been verbally reminded of their responsibility to maintain active supervision and awareness of each child's activities at all times. Staff will ensure that children are always within sight or sound and will document activities in the communication log at every transition.  All staff will receive a supervision training refresher.


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

raw_content: Residents were denied snacks as discipline.


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: It was found that staff members were using inappropriate language and making inappropriate comments towards children in care.


summary: HRC42.063(a) - Reporting Incidents and Violations that threaten or impair the basic health, safety or well-being of a child

raw_content: The physical altercation between two employees that was observed by children in care was not reported to licensing as required.

Correction Narrative:
Plan of Action:
1.Immediate Reporting Compliance:
Incidents will be reported to the Texas Department of Family and Protective Services (DFPS) Licensing Division immediately upon discovery.
A designated staff member will be responsible for ensuring timely reporting of all serious incidents within the required timeframe.

2.Staff Training & Policy Reinforcement:
All staff member received retraining on incident reporting requirements, including HRC 42.063(a), to ensure full compliance on 2/24/2025.
Training covered:
-Recognizing reportable incidents
-Proper documentation procedures
-Timelines for reporting to licensing
Training was completed on [2/24/2025], and attendance records will be maintained in employee files.

3. Incident Reporting Procedure Implementation:
Written policy outlining the reporting process was distributed to all employees.
All incidents involving child safety, staff misconduct, or policy violations must be reported immediately to management and documented in an internal incident log.
Management will review all incidents within 24 hours to determine if they meet the criteria for reporting to licensing.

4.Accountability & Monitoring:
Any staff member found failing to report serious incidents will be subject to disciplinary action, up to and including termination.
The House Manager or designated supervisor will conduct random audits of incident reports to ensure compliance with licensing requirements.
The Administrator will verify that all serious incidents are reported as required.

5.Prevention Strategies:
All staff members involved in the altercation was immediately terminated.
Conflict resolution training will be provided to all employees to prevent future altercations.
Staff will be reminded of the professional conduct policy and expectations for workplace behavior.
A zero-tolerance policy for workplace violence will be strictly enforced.


summary: 748.303(e)(7)(A) - Report to Lic. as soon as you become aware of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident

raw_content: An employee was arrested on 2/9/25, and the incident was not reported to licensing as required.

Correction Narrative:
Plan of Action:

1.Immediate Reporting Compliance:
All arrest will be reported to the Texas Department of Family and Protective Services (DFPS) Licensing Division immediately upon discovery.
Going forward, all employee arrests, indictments, or criminal complaints will be reported within the required timeframe per licensing regulations.

2.Staff Training & Policy Reinforcement:
All administrative staff, supervisors, case manager and direct care staff received training on incident reporting requirements, focusing on:
Recognizing incidents requiring reporting to licensing
Proper documentation and communication protocols
Licensing timelines and compliance expectations
Training was completed by [2/18/2025] and signed acknowledgment forms will be kept in employee files.

3.Incident Reporting Procedure Implementation:
A written policy outlining the required reporting process for employee arrests and law enforcement involvement will be distributed to all staff.
The policy will specify that:
-Any staff member arrested, indicted, or facing a criminal complaint must notify management immediately.
-Management will be responsible for documenting and reporting the incident to licensing within the required timeframe.

4.Accountability & Monitoring:
Failure to report an arrest will result in progressive disciplinary action, up to and including termination.
The Administrator or House Manager will audit personnel records quarterly to verify compliance with reporting requirements.

5.Prevention Strategies:
During new employee orientation, staff will be informed of their obligation to self-report any arrest or criminal involvement.
Regular compliance reminders will be provided to staff through meetings and written notices.


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 were observed making facial expressions, pinching their nose, and spraying around a child with poor hygiene.

Correction Narrative:
Plan of Action:

1.Immediate Staff Counseling & Accountability:
The staff members involved will receive immediate coaching and corrective feedback regarding professional behavior and sensitivity towards children in care.
A written warning will be issued to the employees involved, emphasizing the importance of maintaining professionalism and respect.

2.Training & Reinforcement:
All staff was required to attend mandatory training on 2/24/2025:
Professionalism and appropriate conduct in a childcare setting
Trauma-informed care and empathy training
Addressing hygiene concerns with sensitivity and respect
Training was completed on 2/14/2025, and attendance records will be maintained in employee files.

3.Revised Hygiene Support Plan for Children:
Staff will receive guidance on how to compassionately assist children with hygiene concerns, including:
Private discussions to encourage self-care
Offering appropriate hygiene products discreetly
Creating a supportive and non-judgmental environment for personal care
Staff will be prohibited from making gestures, comments, or actions that could embarrass or demean a child.

4.Supervision & Monitoring:
The House Manager and shift supervisors will conduct random observations to ensure staff are demonstrating professional behavior at all times.
Any future incidents of inappropriate conduct will result in progressive disciplinary action, up to and including termination.

5.Positive Culture Reinforcement:
Team meetings will include discussions on fostering a respectful and supportive environment for all children.
Staff will be encouraged to model appropriate hygiene behaviors and assist children in a way that maintains dignity and self-esteem.


summary: 748.1205(a)(9) - Admission Documentation-Includes chronic health conditions

raw_content: The documents did not include the child's chronic condition.

Category: Admission, Service Planning, Discharge

Correction Narrative: The operation submitted a corrective action plan via email on 2-3-25. The operation will ensure all admission documentation includes chronic health conditions and conduct a thorough review during intake.


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

raw_content: The service plan and/or preliminary plan did not obtain the high risk behaviors.

Correction Narrative:
The operation submitted a corrective action plan via email on 2-3-25. The operation will Ensure high-risk behaviors are assessed and documented upon admission. The operation will re-train staff on identifying and recording high-risk behaviors.
The previous safety plan has been revised to include accurate information.


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

raw_content: The Preliminary Service Plan does not include all the immediate needs specifically documented for each child.

Standard Risk Level: Medium Low

Correction Narrative: The operation submitted a corrective action plan via email on 2-3-25. The operation will revise the Preliminary Service Plan template to capture all immediate needs within 72 hours.


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

raw_content: Documents did not have the accurate information as per policy.

Correction Narrative: The operation submitted a corrective action plan via email on 2-3-25. The operation will implement a double-check system to verify records for accuracy and completeness.


summary: 748.1385(10) - Service Plan Review-Must document the names of the persons participating in the review and update

raw_content: No signitures were found for the Service Plan of a diagnosed autistic child.

Standard Risk Level: Low

Correction Narrative: The operation submitted a corrective action plan via email on 2-3-25. The operation will implement a verification system requiring all participants to sign and confirm their involvement in the Service Plan review to meet the services required for the children in care.


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

raw_content: Individual allowed contact with children in care prior to receiving eligible BGC results.


raw_content: The child's Preliminary Service plan list the name and discharge information of a different child.

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

Correction Narrative:
12/19/2024 Compliance Response received via email:
This was corrected by the case manager immediately.
12/20/2024 Lic. Rep sent an email to operation requesting steps that will be taken to limit and/or ensure accurate information is documented.
12/20/2024- received the following from operation: case manager will undergo mandatory training on proper documentation procedures, including the importance of ensuring accurate, true, and complete records for each child.
Schedule periodic audits of service plans and case files to identify and correct errors before they can impact care or compliance.
Per operation an AR will not be requested.


summary: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

raw_content: A child in care receiving treatment services did not have a service plan review conducted timely.

Correction Narrative:
An email was received stating the operation's plan for correction.

"This Service plan was completed however, however signatures from all parties where not completed. Moving forward GP will make sure all plans are completed and signed in a timely manner, By Training staff on the importance of timely service plan reviews and procedures for ensuring compliance and conducting staff meetings to review upcoming deadlines and ensure all plans are on schedule."


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

raw_content: Review of records obtained during an investigation indicates that at least two children in care files are missing TB results.

Correction Narrative:
9/27/2024 Follow up conducted with operation administrator via phone and email. Proof of TB results received.

9/4/2024 CAP received via email from Greener Pasture: Review the current intake and record-keeping procedures to ensure compliance with 748.1583(b). And making sure all client files are up to date and current.


raw_content:
During the course of the investigation three children in care reported over hearing caregivers used profane language.
The caregiver profane language was not directed towards children.

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:
9/20/2024 Follow-up inspection completed, children in care were interviewed. There were no concerns noted.

8/20/24 Licensing Rep received email from operation: Greener Pastures staff was debriefed on the importance of words used around the children and making sure no profanity is being use at all while at Greener Pastures.


summary: 745.8411(a) - Responsibilities - Not interfere with an inspection or investigation

raw_content: During the course of an investigation, it was discovered that employees at the operation were interfering with an ongoing DFPS investigation by coaching another employee on what to say and not to say during an investigation interview.

Correction Narrative: Assessed by interview.


raw_content: During the course of an investigation, it was discovered that the incident reported did not reflect the accurate details of the incident.

Correction Narrative: Reviewed incident reports and discussed during interview.


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

raw_content: Personnel file missing documentation of contacts made to verify new hire employment history.

Correction Narrative:
9/4/2024 CAP received via email from Greener Pastures:
Ensure that all necessary documentation is completed and added to the personnel files within 4 days and Moving forward making sure all employees has pre screening completed.


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: The employee's personnel file did not have documentation showing references were contacted.

Correction Narrative: 9/4/2024 CAP received via email from Greener Pastures: Review and update the pre-employment screening process to ensure that all required documentation, including verification of employment history and references, is completed before finalizing the hire.


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

raw_content: The operation did not report an outcry made by a child in care of SXAB by a caregiver to Licensing when they became aware of the allegation.

Correction Narrative:
9/30/2024 Staff training certificates received for reporting serious incidents.

9/4/2024 CAP received via email from Greener Pastures: Administrator Provide training for Case Manager and House Manager and on the importance of timely reporting of serious incidents, including the steps to take when an allegation is made.


summary: 748.303(a)(3)(B) - Serious Incident-Report to parents allegations of abuse, neglect, or exploitation of a child directly after ensuring the child's safety.

raw_content: The operation did not report an outcry made by a child in care of SXAB by a caregiver to the childs guardian when they became aware of the allegation.

Correction Narrative:
9/30/2024 Staff training certificates received for reporting serious incidents.

9/4/2024 CAP received via email from Greener Pastures:  Administrator will review and reinforce the incident reporting policies to ensure that all staff understand the urgency of reporting allegations of abuse, neglect, or exploitation immediately.


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

raw_content: During the course of the investigation, the child reported being slammed against the wall by staff.

Correction Narrative: EBI certificates reviewed and discussed during interview.


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

raw_content: Operation did not call in to report when they became aware of an allegation made by a child in care of being sexually assaulted by another child.

Correction Narrative: Discussed procedure during interview.


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

raw_content: During the investigation, the child and one employee reported the child hair was pulled during the restraint by direct care staff.

Correction Narrative: Review EBI certificates and discussed during interview.


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

raw_content: Fire and Weather drill form does not specify the types of drills being performed.

Category: Safety and Emergency Practices

Correction Narrative: An email was sent updating the Types of drill added to the drill report.


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

raw_content: The operation's med log does not include (4) strength of the dosage, (6) the name or signature administering medication, (7) space for applicable refusal.

Category: Medication

Correction Narrative: An email was sent regarding the Medication log as it now includes all required information.


summary: 748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met

raw_content: A room with the square footage for the capacity of 1 occupant was observed to have 2 beds in it.

Category: Physical Site

Correction Narrative: A Picture of the room was sent regarding the bed being removed for the room.


summary: 748.101(3) - Plans to submit - sketch of operation's floor plan

raw_content: The floor plan of the operation did not address dimensions and the purpose of all rooms.

Correction Narrative: An email was sent regarding an update to the Floor plan as it was completed with all requirements.


summary: 748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols.

raw_content: Based on the review of the operation Suicide Policy it was observed there was no postvention team created with a plan of action or protocol.

Correction Narrative: It was observed via email a Postvention team was created and added to the suicidal and prevention policy with a plan of action.


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

raw_content: Observed AWOL log did not contain an area to document a child's age or the time of the unauthorized absence.

Correction Narrative: An email was sent as the Awol log now includes all required information.


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

raw_content: During the application inspection it was found that organizational chart does not accurately reflect hirable positions at the operation.

Correction Narrative: An email was sent updating the Organization Chart as it now reflects the job roles that would be hired at operation.


summary: 748.3309(1) - Communication-Operation must have operable telephone with an outside line, accessible to employees, with listed number, and not coin-operated

raw_content: The operation does not have an opperable facility line.

Correction Narrative: An email was sent stating the facility has a facility line. At&t would be at the facility to contact it properly. This would be the number once (281) 809 3147. this was verified as I call the number on 02/05/2024


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: The operation did not have provisions for refrigerated medications.

Correction Narrative: The operation provided proof of a small refrigerator being purchased regarding storage for cold medication.


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

raw_content: There's was not an appropriate document to record a discussion following a restraint.

Category: Emergency Behavior Intervention

Correction Narrative: An email was sent from the administrator with an EBI debriefing form created with all required information.


summary: 748.105(4)(B) - Personnel policies-develop professional staffing plan that describes qualifications/duties/responsibilities/authority of professional positions.

raw_content: During the application inspection it was observed that the Program Director was missing a description in the staffing plan.

Correction Narrative: An email was sent updating the Program Director duties as it now reflects accurately according to the staffing plan.


summary: 748.455(a)(1) - Unauthorized Absence  The debriefing should include the circumstances that led to the unauthorized absence

raw_content: It was observed that the operations AWOL debriefing document does not address the circumstance, condition of the child and the reason why the child was AWOL.

Correction Narrative: An email was sent updating the unauthorized debriefing form as it was created with all required information.


facility_name: BRIGHTER TRANSITIONS LLC

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

raw_content: It was determined that the operation is not mitigating the risk when children are taking each other's personal items. It was also determined that an older child was giving a younger child a bath, but the caregiver was present and was not supervising them.

Correction Narrative:
Monitoring Inspection ID 4100739
RCCR interviewed the children at the operation, and they stated they receive an allowance, and the staff has given them the option to either keep it with them or have the staff lock it up; they will get it back when they go shopping.

An email was sent by the operation on 3/2/2026 stating that:
A training will be completed with all staff by the end of March regarding caregiver responsibility. The children have all been informed they have the option to lock up all their money in the medication closet. We are working on preparing a document if they refuse to lock up their money then it is not on Brighter Transitions if something happens to their money. They were also informed they could use their money to purchase their own lock box.


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

raw_content:
The people list was reviewed, and the former administrator
did not have their background check inactivated within seven days of leaving the operation on 12/1/25.

Correction Narrative: The background check was made inactive on 12/15/2025.


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

raw_content: Youth in care made an outcry and mentioned wanting to harm themselves on 10-24-25. There was no suicide screening administered.

Correction Narrative:
Received corrective action plan from administrator stating that staff will be re-trained. All direct care and supervisory staff will complete retraining on the approved suicide screening tool by 2/28/2026. Training will include recognizing warning signs, immediate administration requirements, documentation standards, supervisor notification, and safety planning procedures.

Brighter Transitions is committed to ensuring youth safety and maintaining full compliance with minimum standards. Corrective measures have been implemented to prevent recurrence.


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

raw_content: The freezer thermometer was observed to be at negative fifteen degrees celcius which is equivalent to five degrees Farenheit. This was corrected during the inspection by changing the thermometer to negative eighteen degrees celcius which is below zero degrees Farenheit.


summary: 748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved

raw_content: 1 out of 1 serious incident report reviewed did not include the gender and the date of admission of the child.

Correction Narrative: RCCR Inspector received an email from the case manager containing the updated serious incident report form that included the date of admission and the gender.


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

raw_content: 3 out of 3 first aid kits did not have disposable gloves.

Correction Narrative: Disposable gloves were observed inside the first aid kit.


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

raw_content: 1 out of 1 serious incident report did not include the operation's physical address and the telephone number.

Correction Narrative: RCCR Inspector received an email from the case manager containing the updated serious incident report form that included the operation's address and the telephone number.


summary: 748.3273(6) - First Aid Kits-Each one must contain scissors

raw_content: 3 out of 3 first aid kits were missing scissors.

Correction Narrative: A pair of scissors were observed inside the first aid kit.


summary: 748.363(12) - Personnel records-Include record of training and training hours.

raw_content: Personnel record reviewed during inspection was missing the required documentation regarding the training completed and hours completed.

Correction Narrative: The administrator will ensure all required training is completed on time. The operation will also include a checklist in front of the staff's files with updated dates to ensure they track all training and due dates. The administrator will also keep an excel spreadsheet and look at it weekly.


facility_name: Alafia Haven

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

raw_content: During the inspection, 1 staff member was found to not have the instructor led medication training.

Category: Training and Professional Development

Correction Narrative: Compliance was met on 4/12/25, by the CEO providing a certificate of training completed by the employee.


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

raw_content: During the inspection, 4 employee files did not have documentation of verification of employment made by the operation.  Some documentation regarding verification of employment was incomplete or there was some partial information listed.

Category: Personnel

Correction Narrative: Compliance was met on 4/12/25, by the CEO informing that the operation has brought on additional personnel, including an HR/Executive Assistant who will be handling employment verification and all communication with the applicant's previous employers. In addition, monthly audits to ensure ongoing compliance and accuracy of documentation.


summary: 748.881(2) - General pre-service training curriculum-Includes measures to prevent, identify, treat, report suspicion of child abuse, neglect, and exploitation

raw_content: During the inspection, 1 staff member did not have the pre-service mandatory reporting training on file and has been employed as of October 2024.

Correction Narrative: Compliance was met on 4/12/25, by the CEO providing a certificate of training completed by employee. In addition, pre-service training was listed on the personnel file checklist.


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

raw_content: During the inspection, there was not a staff member on site who could provide records for immediate review. Licensing representatives waited approximately 45 minutes for a staff member to arrive on site for assistance. Licensing representatives then had to wait an additional 45 minutes for records to start being provided, upon the staff member arriving to the operation and having a scheduled interview with a potential employee. There was not another staff member who could provide records.

Correction Narrative: Compliance was met on 4/12/25, by the CEO informing that the operation has brought on additional personnel, including an HR/Executive Assistant.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: During the inspection, 2 staff did not have documentation of a TB test. 1 staff has been having contact with children in care for over 2 months and another staff for over 5 months.

Correction Narrative: Compliance was met on 4/12/25, by the CEO providing completed TB tests for the employees.


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

raw_content: During the inspection, 4 employee records did not have documentation of references contacted or there was incomplete or partial information listed.


summary: 748.1205(a)(5) - Admission Documentation-Includes date of admission

raw_content: In a review of admission assessment's, 1 child in cares date of admission was not documented on the admission assessment.

Correction Narrative: Alafia CEO sent an email with compliance of a meeting being held on 2/27/2025, with Alafia staff. The following documents were provided for compliance: Admissions checklist to include date of admission, meeting held with staff on 2/27/25 and the sign in sheet.


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

raw_content: The operation has children in care but hasn't conducted a severe weather drill.

Correction Narrative:
Staff will continue to be provided with additional training on the importance of severe weather drills, including how to appropriately respond to severe weather alerts and evacuation procedures.
Regular discussions will be held during staff meetings with staff to ensure they understand their responsibilities during these drills.
Alafia Haven will conduct severe weather drills at least once every 6 months to ensure continuous preparedness.
The drills will be adapted as necessary based on weather risks in the area and the specific needs of the facility.


summary: 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

raw_content: In a review of documentation provided, one child in care's serious incident report did not have documentation of the parent/managing conservator being notified, along with no date/time for the notification. Additionally, the incident report did not have documentation of the date/time for the notification to law enforcement.

Correction Narrative: Director, Shameka Garner, sent a follow-up email on 1/03/2025, with a sign in sheet of a documented meeting/training for staff in documenting and reporting incidents.


summary: 748.1205(a)(6) - Admission Documentation-Includes medication the child is taking

raw_content: In a review of documentation provided, one child in care's initial admission assessment did not have documentation of her medications. It was documented that the child is diagnosed with a medical health condition and would take her medications as prescribed, but her medications were not documented on the assessment.

Correction Narrative: Director, Shameka Garner, sent a follow-up email on 1/03/2025, with a sign in sheet of a documented meeting/training for staff in review of admission documentation and retraining.


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

raw_content: 2 out of 2 children's files evaluated did not have contraindications to the use of restraint listed on the admission documentation.

Correction Narrative: Administrator has added a checklist to ensure all children are files are completed. The administrator will complete an audit bi-weekly to ensure the files are filed out and completed per minimum standards requirements.


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: 1 out of 2 children rights reviewed were missing signatures.

Category: Children's Rights


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: 1 out of 2 children's file is missing the results of TB testing.

Category: Child Care

Correction Narrative: The administrator will complete and audit bi-weekly of all files meet minimum standards requirements. All files were reviewed on 10/28/2024 via email.


facility_name: Emerging Grace Ministries

summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: During the monitoring inspection, it was observed that one employee file did not have the Affidavit for Applicants For employment (form 2985) notarized.

Correction Narrative:
To address the deficiency cited above, the operation submitted the following compliance plan in response:

The form was signed and in addition the operation is arranging for an additional notary to be available as backup to ensure timely completion of form 2985 and other documents that may require a notary review. ( the notarized form was also attached and placed in the document library)


summary: 748.561(2) - Responsibilities of Professional level service provider-Developing, reviewing, and updating of service plans for a child in care

raw_content: Upon review of the victim child's service plan, it was noted various sections were missing, which need to be addressed per Minimum Standards.

Correction Narrative: The child treatment plans have been updated to meet all minimum standard requirements for DFPS, SSCCs, and private placements.  See document library.


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

raw_content: The serious incident report completed was missing several sections, including: 1) No physical address of phone # on report, 3) No age or gender on the form, 8) Interventions made during and after visit, 9) the treating healthcare professional's name, findings, and treatment,  and 10) the resolution of the incident.

Correction Narrative: The serious incident forms were updated/improved to meet all the requirements for minimum standards. Please see documentation library.


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: During the staff record review, it was noted that the pre-employment drug test results were received on 3/6/25, after staff had already begun working with residents.

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


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: During the staff record review, it was noted that staff received EBI training after working with residents alone at night.


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

raw_content: During the staff record review, it was noted that staff had been working with residents without a TB screening.


raw_content: When reviewing child right's rights two forms were missing the signatures and dates.

Standard Number / Description: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

Correction Narrative: EGM staff will use the admissions checklist as a guide to be sure all required documentation is completed in a timely manner. The administrator will conduct a monthly audit to ensure all requirement is completed.


summary: 748.1223(d) - Admission-Report and findings of medical exam must be documented in child's record

raw_content: Two child files reviewed are missing medical exam.

Correction Narrative: A checklist will be created by the administrator and check bi-weekly to ensure it's being completed thoroughly. If the child in care is from out of state the administrator will ensure to communicate with the case manager and case worker for completion in a timely manner.


summary: 748.3001(a) - Sanitation Inspection-State or local sanitation official must conduct a sanitation inspection

raw_content: Annual health inspection has expired.

Deficiency Narrative: Annual health inspection has expired.

Correction Narrative: The administrator will set a reminder in the operations outlook calendar of the annual inspection so that it does not expire before getting the exemption letter completed. The administrator will conduct a monthly check of all subchapter S to ensure every requirement is addresses in a timely manner.


summary: 748.1437(6) - Discharge/Transfer Documentation-Must include copy of any treatment for a physical condition that is in progress and requires follow-up

raw_content: A child's record did not have a copy of any treatment provided.

Correction Narrative: Discharge paperwork was completed, but not in the resident's file. A Discharge Checklist was created to be used for future discharges. The administrator will conduct a monthly audit to ensure all require documentation is complete.


raw_content: Incident was reported by operation and no serious incident report was created.

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

Correction Narrative: The protocol for documenting an incident report. When an incident occurs, the LCCA is notified and the house manager who is on-site. The information is given to the LCCA and an incident report is generated at that time. In this situation, the incident was not reported to the operation or witnessed by anyone at the operation. However, immediate action was taken and the staff was eventually terminated.


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 had inappropriate boundaries with child in care. Staff was calling a child in care names. Staff was twerking and touching a child inappropriately.

Correction Narrative: EGM leadership includes general responsibilities, including maintaining appropriate boundaries, in orientation training as well as annual training.


summary: 748.751(b)(1) - Pre-Employment Screening-You must document the applicant's employment history in the personnel file.

raw_content: Two staff files reviewed didn't indicate that operation contacted previous employers due to there being no results of this information.

Correction Narrative: The administrator completed all staffs pre-screening and submitted copies to RCCR. The administrator will conduct monthly audits to ensure the pre-screening documentations are being completed in prior to being offer a position at the operation. The administrator will evaluate all documentations in a staff file prior to offering an candidate a position at the operation.


summary: 748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

raw_content: The preliminary service plan is not signed by the Treatment Director or PLSP.

Correction Narrative: Administrator/Treatment director has signed the preliminary service plan and added a signature box to the form. The administrator will do a random check weekly to ensure all forms in child's records will be completed properly.


raw_content: The child's rights document was observed not to be signed by the child.

Correction Narrative: Administrator will ensure the child in care signs at time of in processing. The staff will be trained on all in processing requirements with time limit to ensure all requirements are completed in a correctly. A check list was added to child in care file.


summary: 745.4151(a) - Operation must adopt the DFPS drug testing policy or have its own that meets or exceeds criteria for model policy

raw_content: The operation's drug test policy doesn't include a list of the drugs that the operation screens for and the drug test report doesn't include all the drugs tests based on Texas Administrative Code (TAC).

Correction Narrative: The operation provided a new policy that included a list of the drugs the operation will be screening for based of Texas Administrative Code. The operation will ensure all staff members sign and date the policy.


facility_name: DeFlourish Home, LLC

summary: 748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others

raw_content: The child's service plan had no high-risk behaviors listed as well as no mention that the child is one on one supervision due to behavior.

Correction Narrative:
A compliance email was provided by the treatment director on 10/13/2025, with an updated service plan to include high-risk behaviors and level of supervision required.

An in-person follow-up inspection was conducted on 10/13/2025, by the licensing representative. The treatment director discussed that discussions with the CEO have occurred during a monthly meeting that address updating a service plan with high-risk behaviors and the level of supervision required. The treatment director also made new updates to the child's service plan and went over the service plan with the licensing representative.


summary: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child

raw_content: In a review of the DFPS investigation, it was found that a staff member bit a child in care, which resulted in the child sustaining bruising to the upper left shoulder.

Correction Narrative:
RCCR inspector received a compliance email from DeFlourish Director on 8/19/25, with the agenda and staff sign in sheet for in-service training held on 8/15/25, over abuse/neglect awareness and the understanding that youth may verbally/physically abuse staff, but staff must never abuse youth and that biting a child is not an option either. In addition, it was discussed that restraints are not a form of punishment.

RCCR inspector conducted an in person follow up inspection on 8/22/25. One staff was spoken to about retraining after RTB. Staff were trained in de-escalation and restraint safety along with discipline training.


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

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

Correction Narrative:
RCCR inspector received a compliance email from DeFlourish Director on 8/19/25, with the agenda and staff sign in sheet for in-service training held on 8/15/25, over abuse/neglect awareness and reporting.

RCCR inspector conducted an in person follow up inspection on 8/22/25. One staff was spoken to about retraining after RTB. Staff were trained in de-escalation and restraint safety along with discipline training.


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

raw_content: In a review of the DFPS investigation, it was found that a staff member had conducted an inappropriate restraint on 2 separate occasions during a non-emergency situation by dragging the child out from under a couch and by picking the child up to escort the child to their bedroom, as well as picking the child up again on a different occasion to escort the child outside when leaving a facility.

Correction Narrative:
RCCR inspector received a compliance email from DeFlourish Director on 8/19/25, with the agenda and staff sign in sheet for in-service training held on 8/15/25, over restraint safety and techniques/protocols.

RCCR inspector conducted an in person follow up inspection on 8/22/25. One staff was spoken to about retraining after RTB. Staff were trained in de-escalation and restraint safety along with discipline training.


summary: 748.2855(a)(12) - EBI Documentation- Must include the actions the caregiver(s) took to facilitate the childs return to normal activities.

raw_content: A restraint report dated 12.05.2024 doesn't include information regarding the child's return to normal activities.  This section was blank during the inspection.

Correction Narrative:
The operation provided the following corrective action on January 13, 2025:
1.	Online Forms Implementation:
o	All restraint and EBI documentation forms have been moved online to ensure more efficient and standardized documentation.
o	The online forms now include a required section that specifically asks for information regarding the youth's return to normal activities after a restraint, which will be filled out by staff. (See Attached)
2.	Staff Retraining:
o	We conducted retraining for staff on the importance of completing all sections of the EBI documentation, with a focus on the return-to-normal-activities section.
o	Staff were reminded that this section is critical and ensures that proper care is provided following a restraint.
o	Staff were also encouraged to type out the Serious Incident documentation instead of writing it out.
Attached Documents:
	Attached are the updated Serious Incident Reporting form and the new online EBI documentation system.
	Copies of agenda and sign in sheet provided to staff during the training session on January 9, 2025.
Compliance Timeline:
	All staff were retrained on restraint documentation. It was completed as of January 9th, 2025. See attached for agenda and sign in sheet.
	The online system for EBI documentation is now fully operational, and all relevant forms are being completed according to the updated protocol.
	Ongoing staff education and audits of documentation will occur monthly to ensure continued compliance.


summary: 748.313(4) - Serious Incident- physical or sexual abuse by another child - document differences in size/age/developmental levels of children involved

raw_content: Serious incident report dated 01/02/2025 is marked as "yes" or "no", but the report doesn't document the differences, and more than one child was involved based on the report.

Correction Narrative:
The operation provided the following response on January 13, 2025:
1.	Staff Training:
o	A general staff training session was conducted to educate all staff on the proper procedure for filling out Serious Incident Reports on 1/9/2025. (see attached for sign in sheet and Agena)
o	Emphasis was placed on the necessity of documenting differences in size, age, and developmental levels of children involved in serious incidents, as well as providing clear descriptions for each involved child.
o	The training also covered the importance of accurately following the report instructions, particularly regarding the de-identification of other youth involved by using their initials.
2.	Implementation of New Reporting Protocol:
o	Staff were trained on 1/9/2025  to ensure that all Serious Incident Reports are completed in compliance with the requirements. This includes more thorough documentation of any incidents involving multiple children, with careful attention to their size, age, and developmental levels.
o	Supervisors will be required to review each Serious Incident Report for completeness and accuracy before submission


summary: 745.619 - Background Check Requirements - Submit All Identifying Information

raw_content: The background check for the treatment director was submitted as a frequent visitor.


summary: 748.751(a)(1) - Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.

raw_content: Employee files only included one place of employment.

Correction Narrative:
Operation provided the following compliance plan:
1.Policy Update: Revise the pre-employment screening policy to emphasize the requirement of obtaining a written employment history for the last five years from each applicant before hiring.
2. Form Integration: Add the pre-employment screening form, including the reference check form, to the employee application packet to ensure it is completed during the hiring process.
3. Procedure Enhancement: Use the pre-employment screening form so that applicants must complete during their onboarding, detailing their employment for the past five years.
4. Training: Train staff involved in hiring effective reference-checking techniques and the importance of thorough verification.
5. Record Keeping: Ensure that completed reference check forms are included in the applicant's file as part of the mandatory documentation.
6. Audit and Compliance: Implement a quarterly audit process to review a random sample of hiring files to verify compliance with the employment history requirement.


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: Employee files did not include documentation of reference checks.

Correction Narrative:
Operation provided the following compliance plan:
Corrective Actions:
1. Policy Update: Revise the pre-employment screening policy to emphasize the requirement of contacting at least two references for each applicant.
2. Procedure Enhancement: Develop a standardized reference check form to document the feedback received from
each reference contact.
3. Form Integration: Add the pre-employment screening form, including the reference check form, to the employee application packet to ensure it is completed during the hiring process.
4. Training: Train staff involved in hiring effective reference-checking techniques and the importance of thorough verification.
5. Record Keeping:
Ensure that completed reference check forms are included in the applicant's file as part of the mandatory documentation.
6. Audit and Compliance:
Implement a quarterly audit process to review a random sample of hiring files to verify compliance with the reference-checking requirement.


facility_name: Revival Heart RTC

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

raw_content: Two children in care were identified to need treatment services that the operation is not licensed to provide.

Correction Narrative: The operation will be voluntarily suspending effective 3/25/26 and will no longer be operating. Before the operation is active again operational policies and services provided will be verified.


summary: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: Staff did not complete 40 hours of supervised child-care experience at the operation and/or another operation that provides the same treatment services.

Correction Narrative: Caregivers were completing 40 hours of observation upon initially being hired, but it was not documented. The operation updated the documentation in each caregiver's file.


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

raw_content: Caregivers have no completed 4 hours of EBI refresher training.

Correction Narrative: The operation followed up with the EBI trainer and received all refresher training certificates for current caregivers/employees. Moving forward, the operation will also ensure they file copies of the training sign-in sheets that include the instructor's name, title, training title, and number of training hours.


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

raw_content: The operation did not have dated copies of menus for the last 90 days at the time of inspection.

Correction Narrative: The operation prints out the menus to post them for the month in the operation. The operation created a file and will ensure to keep menus for at least 90 days.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: A staff counted in ratio did not complete 16 hours of EBI training.

Correction Narrative: The operation followed up with the EBI trainer and received all training certificates for current caregivers/employees. Moving forward, the operation will also ensure they file copies of the training sign-in sheets that include the instructor's name, title, training title, and number of training hours.


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

raw_content: Staff files reviewed during inspection did not have documentation to show staff knowledge at the end of EBI training.

Correction Narrative: Post test with results were collected for all caregivers and placed in the files. Moving forward, the operation will collect the post test at the end of the training and file in each employee file thereafter.


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

raw_content: Staff files reviewed at inspection did not have additional documentation to show a portion of the psychotropic medication training was instructor-led by a health care professional or pharmacists.

Correction Narrative: All employees and caregivers who hadn't had the instructor-led portion of the administration of psychotropic medication training have been scheduled for training with a health care physician on February 23rd. The training was completed as scheduled.


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: At the time of inspection, the operation had a fire inspection conducted on 12/26/2025 but were required to make modifications, re-apply for occupancy, and then could be scheduled for a follow up inspection.

Correction Narrative: Operation was unable to come into compliance prior to the end of the second initial, so the operation voluntarily closed.


raw_content: In 1 personnel file reviewed at inspection, the employee listed and the operation verified no reference checks.

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

Correction Narrative: The operation had the employee update the information and conducted the follow up. Moving forward the operation will continue to utilize the HHS Pre-Employment form and ensure contact is made with at least 2 references and documented prior to offering future employees the position.


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

raw_content: In 1 staff file reviewed during inspection, form 2895 was not completed before the staff was hired.

Correction Narrative: The operation updated the employee file to include notarized affidavit form 2895. The operation will audit files moving forward.


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

raw_content: In 2 of 3 personnel files reviewed during inspection, the operation did not document the results of contact made with staffs previous employer.

Correction Narrative: The operation updated the employee files to document the results of operation contact made with staff's previous employer. Moving forward, the operation will continue to utilize the HHS Pre-Employment form and ensure contact is made with previous employers and documented prior to offering future employees the position.


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: In 3 of 3 personnel files reviewed at inspection, the operation did not document the results of the operation contacting staff reference checks.

Correction Narrative: The operation updated the employee files to document the results of the operation contacting staff reference checks. Moving forward the operation will continue to utilize the HHS Pre-Employment form and ensure contact is made and documented prior to offering employees the position.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: An incident involving law enforcement responding to the facility occurred on 11/14/25 but was not reported to Licensing until 11/17/25.

Correction Narrative: The RTC has implemented a checklist for staff in the event a child is indicted, charged, arrested, or when police respond. Staff will follow the steps listed on the form which includes contacting the DFPS hotline as well as notifying the Revival Heart RTC Administrator.


raw_content: Staff counted in ratio were observed to have 1hr of EBI training.

Standard Number / Description: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

Correction Narrative: Moving forward the RTC Administrator will conduct audits of employee files to verify accuracy of training hours. The two employees who were observed to be delinquent now both have 8hrs of EBI training. Copies of their Training Certificates were emailed for verification.


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 fire inspection was not completed 12 months from the date of the last fire inspection.

Correction Narrative: The operation developed a spreadsheet that documents each annual fire inspection conducted and a calendar reminder 90-days prior to the annual fire inspection coming due. The current annual fire inspection was completed on 12/26/2025, but there were corrections, required the operation to file for an occupancy permit, and then submit for re-inspection.


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

raw_content: A caregiver did not follow operation policies for 24-hour awake staff as the staff was found asleep by a child in care.

Correction Narrative: Revival Heart RTC implemented a plan to conduct random check-ins for each of the operation's three shifts. The check-ins will be conducted bi-weekly by the facility manager and operation case manager. The check-ins will be done on different days/nights during the week to ensure all staff members are awake during shifts. A random check-ins/24 hour awake policy log was developed and implemented and will be available for review by licensing upon request.


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

raw_content: The current administrator is unable to be physically at the operation and have daily supervision and responsibility of the overall operation.

Correction Narrative: The current licensed administrator and the operation parted ways as of 08/08/2025. The operation advised them awaiting background checks for another licensed administrator before they are able to hire.


raw_content: Three of 3 employee records reviewed did not have a complete notarized Licensing Affidavit for Applicants.

Standard Number / Description: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

Correction Narrative: Form 2985 was shared with the operation. The operation updated all current employee file to include the affidavit. The operation updated the procedure to include the affidavit for future employees.


summary: 748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met

raw_content: The operation does not have 60 square feet of space for each occupant in the first floor bedroom 2 and second floor bedroom 3.

Correction Narrative: The operation responded by removing extra beds and provided photos to show the changes.


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

raw_content: The emergency evacuation and relocation diagram does not show the area outside the operation where caregivers and children will meet.

Correction Narrative: In response to the deficiency, the operation updated emergency evacuation and relocation diagram to show where staff and children will meet outside the operation to evacuate.


summary: 748.105(3) - Personnel Policies - Include procedures for screening applicants to determine suitability.

raw_content: At the time of inspection, the operation did not policies and procedures for conducting reference checks for potential employees.

Correction Narrative: In response to the deficiency, the operation developed and provided a Pre-Employment Screening Template they will use to document reference checks. Policies and procedures were also updated and submitted and evaluated to meet compliance with 748.105(3).


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

raw_content: At the time of inspection, a pile of tree branches towards the back of the property and solar walkway lights piled in the front garden bed.

Correction Narrative: In response to the deficiency, the operation removed the pile of branches, pile of solar walkway lights, and parked car were removed.


raw_content: At the time of inspection, an employee did not have a completed notarized Licensing Affidavit.

Correction Narrative: In response to the deficiency, the operation updated form 2985 and it was notarized.


summary: 748.103(b)(14) - Policies and procedures to submit - A suicide prevention, intervention, and postvention policy consistent with §748.124 of this division.

raw_content: At the time of inspection, the operation did not have policies and procedures for suicide prevention, intervention, and postvention consistent with 748.124.

Correction Narrative: In response to the deficiency, the operation submitted updated policies and procedures for suicide prevention, intervention, and postvention consistent with 748.124.


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 emergency evacuation and relocation diagram does not show the designated area inside the operation where staff and children will meet to shelter from bad weather.

Correction Narrative: In response to the deficiency, the operation updated emergency evacuation and relocation diagram to show where staff and children will meet in the operation to shelter from bad weather.


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: At the time of inspection, there was no documentation to show that references were contacted prior to hiring an employee.

Correction Narrative: In response to the deficiency, the operation provided documentation to show references were contacted prior to hiring an employee. The operation also updated personnel policies to reflect the procedures for conducting references and storing the reference check results in each individual employee file.


summary: 748.127(a) - Operation plans, policies and procedures must indicate date adopted and effective date

raw_content: At the time of inspection, operation plans, policies, and procedures did not show the date they were adopted and effective.

Correction Narrative: In response to the deficiencies, the operation officially updated policies and procedures to be adopted by the board.


facility_name: SAVING HOME RTC LLC

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

raw_content: Staff failed to appropraitely document medication given to a child in care.

Correction Narrative: During the inspection, medication was observed in a secure location with the correct pill count. Children in care's medication dosage was also documented correctly in the medication log. No concerns were noted.


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

raw_content: The medication count for two children in care was not accurate.

Correction Narrative: During the inspection, medication was observed in a secure location with the correct pill count. No concerns were noted.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: Computer documentation indicates that medications are being prepared more than one hour prior to time being dispensed.

Correction Narrative: When observing the medication count, there were no indications that medication was being prepared before dispensing. The inspector was informed that all staff have been properly trained on medication administration.


summary: 748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions

raw_content: Six children's in care medications were stored in a weekly container without the proper prescription information.

Correction Narrative: Medication was appropriately stored in locked boxes and inaccessible to children in care.


raw_content: The medication count for six children in care was not accurate.

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


raw_content: The designated administrator reported that he is not on duty every day at the operation.

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

Correction Narrative: The operation has hired a new administrator who will work at least 30 hours per week and fulfill the daily responsibilities of the role. The background check has been reviewed in the People's List. During the inspection of the operation, the owner informed the inspector that the new administrator will begin the position at the beginning of February 2026.


summary: 748.531(a)(3) - Child-care administrator-Is full-time employee of the operation

raw_content: The designated Administrator for the operation reported working less than 30 hours per week at the operation.

Correction Narrative: The operation has hired a new administrator who will work at least 30 hours per week and fulfill the role's daily responsibilities. The background check has been reviewed in the People's List. During the inspection of the operation, the owner informed the inspector that the new administrator will begin the position at the beginning of February 2026.


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

raw_content: A child in care whose service plan states that the child should be 1:1 during awake hours was seen unsupervised while CCI staff were present at the operation.


summary: 748.311(2) - Serious Incident Documentation-Includes time and date of incident

raw_content: The operation submitted an incident report that did not contain the date and time.

Correction Narrative: Saving home RTC provided a refresher training to all current staff conducted by the Executive Director on 03/13/2026.


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

raw_content: Multiple staff records lacked information about their education.

Correction Narrative: A follow-up inspection was conducted at the operation for staff members' personnel records. Three staff records were reviewed, with no concerns identified. The required information was observed in the records. Compliance has been met.


summary: 748.505(a) - Minimum qualifications for employees-Behavior or health does not present a danger to children in care

raw_content: Multiple staff records lacked a licensed operational affidavit.

Correction Narrative: A follow-up inspection was conducted at the operation for compliance with staff records. Three staff members were reviewed for the operational affidavit, and no concerns were raised.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: During an investigation, it was determined the operation reported a child's arrest past the 24 hours maximum required by the minimum standards

Correction Narrative: On November 21, 2025, the RCCR Inspector received an email from the operation's owner stating that all caregivers received training regarding serious incident reports and a refresher course regarding minimum standards.


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

raw_content:
Children in care have specific supervision needs for one-on-one supervision during waking hours, both within the facility and outside.  The operation has failed to staff the facility appropriately, ensuring that staff can meet each child's supervision needs.  Additionally, on multiple occasions, a group of children, including one child with 1:1 supervision needs, were left unsupervised at a local park.

During a follow-up inspection, two children in care were supervised 1:1, and one child was observed to be unsupervised.

Correction Narrative: The inspector received an email from the operation's administrator. The administrator stated that all caregivers and admins have received training on supervision and the importance of ensuring the safety of children in care at all times.


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

raw_content: One child in care service plan was not completed within the 45 day timeframe.

Correction Narrative: The inspector received an email from the operation's administrator. According to the email, the case manager and treatment director have received training during the timeframe when the service plan and preliminary plans are due.


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

raw_content: Two children in care eloped from the operation while staff were asleep and returned with stolen weapons

Correction Narrative: This standard is being found compliant.


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

raw_content: Two children in care admitted to storing a handgun under their dresser during the operation.


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

raw_content: The operation failed to complete a suicide risk screening or assessment by a mental health professional after a child exhibited self-harming behaviors.


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

raw_content: Two children in care preliminary service plans were not completed within-in 72 hours.


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: The operation staff have failed to maintain the ratio due to one staff member being assigned to a group of three children, including two children who require 1:1 supervision.


raw_content: Children in care have specific supervision needs for one-on-one supervision during waking hours, both within the facility and outside.  The operation has failed to staff the facility appropriately, ensuring that staff can meet each child's supervision needs.  Additionally, on multiple occasions, a group of children, including one child with 1:1 supervision needs, were left unsupervised at a local park.

Standard Number / Description: 748.685(c)(6) - Implement and follow the children's service plans.


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

raw_content: One staff member was missing sucide prevention training.

Correction Narrative: On April 18, 2025, the inspector received an updated suicide prevention training certificate from the operations administrator. The inspector reminded the administrator that the training is required annually.


facility_name: HIS Love Foster Care Solutions

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

raw_content: During an investigation inspection it was found a child's medication log did not include the required information such as the person name and signature of whom administered the medication and the prescribing Dr.'s information. In addition, two medication records were observed with an inaccurate count.

Correction Narrative:
The operation emailed to following compliance into licensing :

THE MARS HAVE BEEN UPDATED TO INCLUDE PRESCRIBING MD INFORMATION AND EACH MAR HAS THE SIGNATURE PAGE ATTACHED AND SIGNED by each staff administering medications,

THE MEDICATION WITH INACCURATE COUNT WAS CORRECTED IMMEDIATELY DURING THE VISIT ON 9/25/2025.

STAFF  WAS RE-TRAINED ON PROPER DOCUMENTATION OF COUNT IN THE LOG BOOK ON 9/25/2025 AT 5:30PM.

ALL PILLS WERE RETURNED FROM LABELED PILL BOXS TO ORIGINAL BOTTLES AND ALL STAFF WAS IMMEDIATELY TRAINED ON ADMINISTERING MEDICATIONS -ON 9/26/2025 AT 2PM FOR MORNING SHIFT , AND AGAIN AT 6PM FOR EVENING SHIFT.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: During an investigation it was observed medications are being prepared several days in advance prior to administration.


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

raw_content: It was determined during this investigation that the operation failed to notify a child's LPS worker of a medication review. This resulted in a child's medication change occurring without the caseworker's consent.

Correction Narrative: As per the operation's Treatment Director, they will ensure that during every psychiatry medication review, every case worker and permanency specialist, and/or LPS Worker is invited to the monthly Psych Meds Review by email as soon as a Psych Appointment is scheduled; the child's LPS Worker will be required to RSVP within 3 days of that email invitation; if theres a change in the childs medication during the Med Review, the Treatment Director will obtain written, signed, and dated consent for a new psychotropic medication from the LPS Worker by completing Form 4526, DFPS for Consent for Treatment with Psychotropic Medication and the form be emailed all parties to document consent before new medication is administered and placed in the child's file. This process is to be effective immediately.


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

raw_content: Based on a review of documentation, it was determined that a child's unauthorized absence was not reported to the parent within the required timeframe.

Correction Narrative:
08/22/2025-The operation's Governing Body submitted to licensing staff via email the operation's Corrective Action Plan indicating as of 08/06/2025, the Governing Body updated internal procedures as well as communicated with all staff regarding updated unauthorized absence procedures requirements based on the operation's policies.

According to the operation's Governing Body, all staff (including 24-Hour Awake Overnight Staff) has been directed to report all unauthorized absences to parent(s) by contacting the Intake Hotline within 2-Hours of unauthorized absence in minimizing future risk of non-compliance.


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: Based on a review of documentation, it was determined that a child's unauthorized absence was not reported Licensing within the required timeframe.

Correction Narrative:
08/22/2025-The operation's Governing Body submitted to licensing staff via email the operation's Corrective Action Plan indicating as of 08/06/2025, the Governing Body updated internal procedures as well as communicated with all staff regarding updated unauthorized absence procedures requirements based on the operation's policies.

According to the operation's Governing Body, all staff (including 24-Hour Awake Overnight Staff) has been directed to report all unauthorized absences to Licensing by contacting the Intake Hotline within 2-Hours of unauthorized absence in minimizing future risk of non-compliance.


facility_name: DIVINE ARMS OF LOVE GRO, LLC

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

raw_content: During the ANE investigation, it was found that a caregiver was not providing the child's school with their prescribed medication, which allowed the child to miss multiple doses.

Correction Narrative: Divine Arms implemented a daily check in with the school nurse to make sure there are no concerns or needs for the youth.


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

raw_content: During the review of the ANE investigation, it was found that a staff member did not use prudent judgment when performing caregiver duties.

Correction Narrative: Reviewed with staff the emphasis on duties Employee Responsibilities and Professionalism. Staff member involved was counseled regarding sound decision-making.


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

raw_content: One child's medication log does not have a time or date for the day that the medication was given.

Correction Narrative: Supervisory staff will conduct audits of medication administration records. Further training will be given.


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

raw_content: Four out of Four children's files reviewed did not have documentation of medication logs.

Correction Narrative: Supervisory staff will continue to conduct routine audits of medication records to confirm completeness and accessibility.


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

raw_content: Multiple first-aid kits were missing items such as tweezers and scissors.

Correction Narrative: Staff will conduct routine checks to maintain ongoing compliance.


summary: 748.4111(a) - Transportation records-Must maintain on file at the operation the name of each driver and a copy of that person's valid driver's license

raw_content: It was noticed that the operation did not maintain a transportation record of who transports children, here at the operation.

Correction Narrative: Administrative staff will conduct periodic audits of transportation records.


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

raw_content: During the walk through the backyard had serval collections of debris and trash in different areas of the yard. Direct staff collected the trash from the yard and program director bought a trash can for the backyard.


summary: 748.3397(b)(2) - Bathing-Provide separate shower and bath facilities for each gender

raw_content: During the walk-through it was noticed that bathrooms were not distinctly marked for genders, and a boy and girl resident were sharing a bathroom.

Correction Narrative: This standard was evaluated and found compliant.


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

raw_content: During the walk-through staff disclosed that the girls cross through a common area to get to another restroom.


facility_name: Hendrick Home for Children

summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: 4 staff files were missing the pre employment affidavit.

Correction Narrative: RCCR inspector received follow up from the operation on 4/10/26. All staff have a completed Pre Employment Affidavit for Employment form. Documents uploaded to document library.


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

raw_content: During the inspection, it was found that 2 out of 3 cottage homes practiced a fire drill within the past 6 months.


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

raw_content: One employee file's Affidavit for Applicants for Employment form was not notarized.

Correction Narrative: Notarized affidavit was received by email. Operation management will continue to ensure documents are filed.


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

raw_content: During the inspection, it was found that 2 out of 3 cottage homes practiced a sever weather drill within the past 6 months.


summary: 745.621(b)(1)(A) - AP Renewal background checks submitted -No later than 5 yrs from date last submitted subjects initial or renewal fingerprint-based criminal hist check

raw_content: One foster parent's background check was run under the wrong name and this was inactive.

Correction Narrative:
The Administrator spoke to the foster parents on 4/1/23 at the inspection and let them know the foster father has to stay in their own apartment away from the children in the main house and not have unsupervised access to the children in care. A new background check was submitted and shows on 4/3/23. The Administrator also emailed the inspector the operation's process for background checks: The background check process is as follows: The Programs Coordinator is responsible for initial submission and renewal of Hendrick Home for Children's background checks. Every employee is given paperwork that permits HHC to run a background check and to renew for background checks as needed when hired. This paperwork is returned to and kept in files. She notates when background check renewals are due, and this is double checked by a second party. She submits renewals as they are due and frequently checks to ensure we are in compliance.
JG


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

raw_content: 2 homes did not have evacuation routes posted in the homes.

Correction Narrative: The administrator emailed the inspector PDF files of the evacuation routes and pictures of the routes posted in the homes.


raw_content: 4 of the 4 homes had not practiced fire and severe weather drills within the 6 month time period.

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

Correction Narrative: The administrator emailed the inspector current fire and severe weather drills for the homes. They went ahead and had everyone do drills this past week, so all the homes are on the same rotation.


facility_name: Sunny Glen Childrens Home

summary: 748.3477(d) - Swings-Child under 4 yrs old may use bucket swing if adult lifts & secures child into swing; bucket swing must be 24 inches from protective surfacing

raw_content: A bucket swing was not 24 inches off the ground. It was approximately only 12 inches off the ground.


summary: 748.3523(b) - Use Zone-Use zones for stationary equipment must not overlap the use zones of any other equipment

raw_content: Two stationary structures were found to have overlapping use zones.


summary: 748.3533(c) - Use Zone-For rocking & rotating equipment must not overlap any other use zone

raw_content: There were two rocking equipment with overlaping use zones. One of the rocking equipment was overlaping the use zone of another stationary/ climbing equipment.


summary: 748.1743(e) - Care requirements for infants- items necessary for diaper changing must be kept out of reach of children

raw_content: A diaper rash cream was observed within a child's reach.


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

raw_content: A preliminary service plan was not completed within 72 hours.

Correction Narrative: Corrections were received on 4/30/25 the case manager will make initial contact with the DFPS Caseworker to request and/or review records when accepting placements. The case manager will draft a preliminary plan within 24 hours and submit it to the Treatment Director for review. The case manager will complete the preliminary service plan within the 72 hours.


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

raw_content: An admission assessment was not completed timely.

Correction Narrative: On 4/3/25 corrections were received from agency. The administrator met with treatment director and the case manager to review minimum standards. The case manager will document information received from DFPS for admission assessment. If information is not provided by DFPS the operation will document, and the case manager will include a case note to reflect the completion of the admission assessment.