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

raw_content:
Upon review of medication records, it was found that  after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days.

Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.


state: TX

facility_name: Castillo Childrens Center

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

raw_content: In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
Upon review of 7 child medication log records, it was found that this standard was in compliance. The logs were reviewed to ensure that the medication was being given to the children as prescribed by the physician. This standard was found to be in compliance.

Interviews with children were also conducted to ensure that their medications were being given properly and timely. All children reported getting the proper medication and that had run out.


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

raw_content: In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.

Correction Narrative: 7/6/2023: During the inspection, the nature of the citation was discussed. The administrator stated that a conversation would be had with the medication tech's who give out the medication today. It was also shared that he planned to hold an emergency medication training session. The child is also no longer at the operation.


summary: 748.1385(5) - Service Plan Review-Must evaluate effectiveness & side effects of psychotropic meds, change in psychotropic meds, child's behaviors and reactions

raw_content: During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.

Standard Risk Level: Medium

Correction Narrative: A review of three service plans were reviewed relating to this standard. These plans were completed in the month of July. The service plans were noted to have the required information as stated in standards. This standard was found to be in compliance.


summary: 748.3233(b)(4)(B) - Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not blocked in any way

raw_content: A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.

Correction Narrative: Upon review of the location of the couch, it was noted that it was not pushed up against the exterior door. The bikes were also observed to be moved out of the way of the door as well.


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

raw_content: In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.

Correction Narrative: The tiles in the bedroom were replaced. The tiles were seen to be new with no peeling or scuffed.


summary: 748.685(e) - Caregiver responsibility-for a child receiving treatment services for an emotional disorder must maintain daily, signed and dated progress notes

raw_content: In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.

Correction Narrative: During inspection, the new daily progress notes were reviewed. It was noted that an area was added for staff to sign their names, as well as date the form. It was noted that the form is to be used effective immediately by direct care staff.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.

Standard Risk Level: Low

Correction Narrative: During inspection, a review of the service plans was conducted. It was noted that all the service plans had the required signatures.


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

raw_content: In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.

Correction Narrative: In a discussion with Administrator, it was noted that the staff member was placed on a 90-day probation. The disciplinary action letter was reviewed.


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

raw_content: During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.

Correction Narrative: An interview was held with six total children at the operation. Out of the six children interviewed, all six stated that no staff has threatened them to gain compliance.


summary: 748.303(e)(6)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of abuse/neglect investigation by other entity of person under auspices of facility

raw_content: A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.

Correction Narrative:
The employee's BGC has been inactivated as
of 03/31/2023, verified online BGC. LCCA's response during inspection and supervisor's meeting with the LCCA insp #3938348 that the employee would be terminated as a result. LCCA provided written documentation of the employee's termination as of 3/31/23.


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

raw_content: An employee failed to comply with requirement to report being under investigation for abuse/neglect.

Correction Narrative: The employee's BGC has been inactivated as of 03/31/2023, verified online BGC. LCCA's response during inspection and supervisor's meeting with the LCCA insp #3938348 that the employee would be terminated as a result. LCCA provided written documentation of the employee's termination as of 3/31/23. LCCA advised to ensure the operation and employee's will comply with operation policy and procedures as well as minimum standards. LCCA advised that continued staff meetings and trainings will be utilized to provide refresher trainings and information.


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

raw_content: Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.

Standard Risk Level: High

Correction Narrative: Standard reviewed and found to be in compliance.


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

raw_content: It was noted that staff did not write EBI documentation in a timely manner.

Correction Narrative: Going forward, EBI documentation will be completed and put into the child's record no later than 24 hours after the EBI. The Case Manager will be responsible for ensuring the documentation is done within the appropriate time frame.


summary: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso

raw_content: Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.

Correction Narrative: Going forward, within 72 hours of the EBI the parent/ managing conservator will be notified in writing of the EBI. The Case Manager will be responsible for this written notification.


summary: 748.3273(9) - First Aid Kits-Each one must contain tweezers

raw_content: Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.

Category: Safety and Emergency Practices

Standard Risk Level: Medium Low

Corrected at Inspection: Yes


summary: 748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times

raw_content: Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.

Category: Physical Site

Correction Narrative: Upon reviewing the playground at the operation, it was seen that there is loose fill sand up to the nine inch mark as noted on the play equippment.


summary: 748.3471(5) - Safety Requirements-Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, etc.

raw_content: Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.

Correction Narrative: Upon reviewing the playground it was noticed that the equipment was correctly anchored to the ground.


summary: 748.535(3)(E) - Child-care administrator responsibilities-Administering and managing the operation according to your policies.

raw_content: Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.

Correction Narrative:
The tutoring program has been discontinued and Castillo Children's Center will not use volunteers.
Additional follow up compliance will be reviewed during the follow up inspection at the operation.


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

raw_content: Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.

Correction Narrative: The tutoring program was discontinued and Castillo Children' s Center will not use volunteers.


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

raw_content: Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.

Category: Medication

Correction Narrative: Upon reviewing medication logs, everything was found to be corrected and documented.


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

raw_content: Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.


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

raw_content: During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.


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

raw_content: Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.

Category: Emergency Behavior Intervention

Correction Narrative: Upon reviewing EBI documentation, documentation was reviewed and had been corrected.


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

raw_content: Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.

Correction Narrative: Upon review at the inspection, the administrator has created a daily playground inspection log and has conducted required trainings for EBI as well as removing the program for the volunteers that did not have background checks.


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

raw_content: Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.

Correction Narrative: An EBI Annual Evaluation was held on 2/20/2023.


summary: 748.2851(d) - EBI Follow-Up-Supervisor(s) of caregivers involved in an EBI must review the use of the emergency behavior intervention within 72 hours

raw_content: Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.


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

raw_content: Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.


summary: 748.721(a) - Volunteer personnel record-The operation must maintain a personnel record for each volunteer

raw_content: Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.

Correction Narrative: The tutoring program was discontinued and Castillo Children's Center will not use volunteers.


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

raw_content: Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.

Correction Narrative:
Per LCCA Tony Castillo, the tutoring program has been discontinued and Castillo Children's Center will not use volunteers.

No background check to be ran due to the operation ceasing the tutoring program, and choosing to not amend their policy to include volunteers. The discontinuation of the tutoring program is effective immediately.


summary: 748.3475(a) - Safety Requirements-The administrator or designee must inspect the playground weekly to ensure no hazards are present

raw_content: Upon discussion with the administrator, it is revealed  that the administrator  has not been inspecting the playground weekly.

Correction Narrative: A playground equipment checklist has been created and will be used to check playground equipment on a weekly basis.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day.  There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.


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: Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.

Correction Narrative: -A severe weather drill was conducted on 2/17/2023 and documented on a severe weather log.


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

raw_content: Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.

Correction Narrative: A fire drill was conducted on 2/17/2023. Fire drills will be conducted every 6 months moving forward.


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

raw_content: Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.


summary: 748.2853(2) - EBI Documentation-Child's reaction to the opportunity for post discussion

raw_content: Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.


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

raw_content: Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.

Correction Narrative: Updated job description for staff member received.


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

raw_content: In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.

Correction Narrative: There was a training update on reporting abuse, neglect, and exploitation on 3/20/2023. Operation sent sign-in sheets and staff assessments to show the training was conducted.


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

raw_content: In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.

Correction Narrative:
4/4/2023: Children were interviewed to ensure compliance. Follow up conversation with Administrator shared no new disciplinary action taken with staff member.

3/24/2023: Staff member was given disciplinary action and placed on probationary period.


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

raw_content: In a video recording, it was heard that a staff member was using profane language towards children.

Correction Narrative:
4/4/2023: Children were interviewed to ensure compliance.

3/24/2023: Staff member was given disciplinary action and placed on probationary period.


summary: 748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months

raw_content: It was found that two employees had expired drivers licenses.

Correction Narrative: Updated driver's license received for one staff member. The other staff member is not to be transporting children nor will she drive any agency vehicles going forward.


summary: 748.941(a)(2) - Training Criteria- Instructor-led/self-instructional training must include a curriculum that includes experiential or applied activities.

raw_content: In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.

Correction Narrative: Operation states that they are aware that a curriculum is needed for trainings. Operation conducted a training on 3/20 and sent a copy of the sign in sheet to show that the trainer was present and noted his qualifications to provide the training.


summary: 748.941(a)(3) - Training Criteria- Must include an evaluation tool to determine whether the person obtained the information necessary to meet the stated objectives

raw_content: In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.

Correction Narrative: A sample training evaluation assessment was sent to show that the operation is implementing the required standard.


summary: 748.941(a)(1) - Training Criteria- Instructor-led/Self-Instructional Training must include specifically stated learning objectives.

raw_content: In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.

Correction Narrative: Operation states that they will going forward add a learning objective on all training sign in sheets. The operation conducted a training on 3/20 and sent the sign in sheet to show the learning objective.


summary: 748.1699(a) - Nutrition-must offer a child a meal or snack, but may not force the child to eat

raw_content: During the course of the investigation, it was found that staff are forcing children to eat all of their food.

Correction Narrative:
3/16/2023: Children were interviewed to ensure compliance.
3/6/2023: Beginning immediately, children will not be forced to eat any portion of their food or snacks.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content:
Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot.
Boxes were removed and thrown in dumpster.


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

raw_content: The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.

Correction Narrative: This was a follow-up inspection. The pantry was found with no evidence of rodent droppings. The pantry shelves were observed to be clean and not sticky.


summary: 745.8417 - Licensing must have access to records

raw_content: Video footage and documentation was not provided during the investigation.

Correction Narrative:
12/9/2022: Phone conversation with LCCA and HHSC staff. LCCA shared that with the video footage that was requested, he attempted to pull a copy to show CCI investigator, but the hard drive was corrupted, and he was unable to pull the footage. Going forward, he will not be recording, and the cameras will only be utilized for live footage. Regarding documentation, he shared that going forward, Case Manager will share documentation requests with him and program coordinator. Thus, there will be more eyes on the request and the ability to get the information request to the investigator.

12/8/2022: Email from HHSC staff requesting a follow-up update to LCCA. Email from HHSC Lic Rep requesting a follow-up and update.

12/2/2022: Email from HHSC Lic Rep to LCCA
Requesting the opportunity for a phone call to have a conversation following the compliance plan. I requested dates/times that work for LCCA.

11/29/2022: Email from LCCA
In response to investigation # 2934931, in which a citation was issued per standard/ Rule Description 745.8417,
The operation will make available, at all times, any and all documentation and/ or video footage, if it exits, that is requested by CCR during any licensing investigation or review.


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

raw_content: Operation did not have a current six month evaluation of Unauthorized Absence.

Category: Reports and Record Keeping

Correction Narrative:
Castillo  Children's Center will conduct Unauthorized Absence Evaluations every 6 months as directed by the standard.

CCC sent the updated UA review to Talin Pape through email. Document is considered to be up to date.


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: One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.

Correction Narrative: Any time there is an allegation or indications of abuse, neglect, or exploitation of a child, it will be reported to the hotline in a timely manner.  The case manager, program coordinator, treatment director, and administrator will be responsible for ensuring the report is made in a timely and appropriate manner.


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 logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.

Correction Narrative: Medication logs will be reviewed daily by direct care staff, three times weekly by a designated medication coordinator, and twice weekly by the program coordinator and case manager in order to ensure the count of the medications is correct and accurate.


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

raw_content: During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"


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

raw_content: Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.

Correction Narrative: Medication logs will be reviewed daily by direct care staff, three times weekly by a designated medication coordinator, and twice weekly by the program coordinator and case manager in order to ensure the reason that the medication is being given is documented appropriately and accurately to the child's diagnosis and symptoms.


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

raw_content: Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.

Correction Narrative:
On the date of the deficiency, 08/31/2022, a new thermometer was placed in the freezer which read 8*F and the temperature was reset to below 0*F. The freezer has been checked on a daily basis since that time and has consistently read at 0*F.
All items in the freezer which read 24*F were removed and placed in another freezer and  the freezer was taken out of service


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

raw_content: One of four child records reviewed did not have documentation off a dental appointment.

Category: Admission, Service Planning, Discharge

Correction Narrative:
A dental appointment was made for the child in question and child medical and dental files will be reviewed biweekly by the case manager and treatment director in order to ensure medical and dental check ups are scheduled and completed on time.

The date of the dental appointment is 10/04/2022 and the child is placed on a cancelation list with the dentist if an earlier appointment becomes available.


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

raw_content: Two of the four child records reviewed were late on the completion of the initail service plan.

Correction Narrative: The case manager has created a document to detail the dates by which children's initial and review plans of service are due.  The case manager will update this document whenever a new resident comes into the care of Castillo Children's Center and it will be reviewed weekly by the case manager, as well as biweekly by the treatment director and administrator to ensure plans of service are completed in a timely manner.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.

Correction Narrative: Medication logs will be reviewed daily by direct care staff, three times weekly by a designated medication coordinator, and twice weekly by the program coordinator and case manager in order to ensure the count of the medications is correct and accurate and that doses of medication are being given as prescribed and documented appropriately.


summary: 748.1433(e) - Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so

raw_content: Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.

Correction Narrative: The treatment director, administrator, and case manager will coordinate a meeting with the child who is being transferred/ discharged no sooner than 4 days before discharge or transfer. Only a qualified professional can justify shorter notification periods


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.

Correction Narrative: Incident reports will be submitted within 24 hours of an incident and the case manager and administrator will review these reports to ensure completion and accuracy within 72 hours of submission, including ensuring a resolution is documented.


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

raw_content: It was determined that a staff member at the operation would yell and raise their voice in front of the children.

Correction Narrative:
Beginning on 07/29/2022 staff member will be on job status probation for 90 days. If this type of substandard job performance is repeated within this 90 day period, disciplinary action, which may include suspension without pay or employment termination, will occur. If this type of work performance does not repeat itself, the probation period will end on 10/22/2022.

Staff Training was also given on 07/29/2022 for a hour. The topic was regarding appropriate discipline and appropriate verbal interaction with Children and Staff.


raw_content: One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.

Standard Number / Description: 748.2203(c)(2) - Medication Error-Document the medication error

Correction Narrative: Medication logs will be reviewed by the program coordinator and case manager twice weekly in order to provide quality assurance. A full count and check for the correct count. If a medication error is discovered, the program coordinator and case manager will determine the medication error and complete a medication error report to account for the medication error. These medication error reports will be organized into a log available for inspection to account for any and all medication errors.


summary: 748.1385(4) - Service Plan Review-Must document reasons for continued placement if review shows no progress towards meeting identified needs

raw_content: Two out of four children records reviewed showed little progress/updates in their service plan reviews.

Correction Narrative: Child records will contain updates including ARD/IEP information, current grades, school behavior reports, and CCC behavioral reports in order to track progress on goals in their service plans. The treatment director and administrator will review plans biweekly to provide quality assurance.


summary: 748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents

raw_content:
Four chip bags were found to be opened and unprotected from external elements located in the kitchen.

Administrator disposed of the open chip bags as well as puchased additional chip clips.


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

raw_content: In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.

Correction Narrative: A photograph was emailed to Talin Pape showing the hole has been patched and covered up.


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

raw_content: In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.

Correction Narrative: All admission assessments will be reviewed by the treatment director and the administrator in order to provide quality assurance upon intake.


raw_content: Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.

Standard Number / Description: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

Correction Narrative: Medication logs will be reviewed by the program coordinator and case manager twice weekly in order to provide quality assurance to ensure all necessary information, including the reason the prescription medication was prescribed, is recorded onto the medication logs.


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

raw_content:
Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly.

Administrator applied drain-o to the sinks to unclog the drains.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content:
In the boys restroom, it was observed that the shower/tub combo was missing a shower head.

Administrator installed a new shower head to the shower/tub combo.


raw_content:
Small freezer in pantry thermometer was reading to be approximately 10 degrees F.
The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken.
The kitchen fridge/freezer combo was missing both thermometers.

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

Correction Narrative:
Photographs were emailed to Talin Pape showing the following:
- Small Freezer in Pantry with thermometer
- Kitchen Fridge/Freezer combo with thermometer in both areas.
- Pantry Fridge/Freezer combo with thermometer added


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

raw_content: Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.

Correction Narrative: Medication logs will be reviewed by the program coordinator and case manager twice weekly in order to provide quality assurance to ensure all necessary information, including the prescribing physician, is recorded onto the medication logs.


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

raw_content: This standard was reviewed and found to be deficient. The medication logs provided only displayed staff initials where a signature is required for administration of medication, and no way to identify which staff member those initials belong to. On one of five medication records, there was no staff signature for the administration of medication given to a child.

Correction Narrative: LCCA submitted corrective plan; staff informed of the procedures including full signature and initials on medication logs. LCCA to address in staff meetings as well. -LG


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

raw_content: A staff member physically grabbed a child by the wrist and legs, leaving a mark on the child.

Correction Narrative:
6/11/21-LCCA submitted training completed by staff on 5/31/21.
5/24/21-LCCA submitted the following correction plan-The staff in question will be scheduled for a refresher training in SAMA. SAMA is the EBI training which Castillo Children's Center uses. Date of the training will be scheduled with the trainer and notification of training completion will be sent to CCR as soon as possible.


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

raw_content: Staff member utilized physical exercise as a form of discipline.

Correction Narrative:
6/11/21-LCCA submitted training completed by staff member on 5/24/21.
5/24/21-LCCA submitted the following correction plan: The staff in question will be provided additional, one on one, training regarding prohibited corporal punishment. Date of training to be determined, but within seven (7) days of this response. Once the training is completed documentation will be sent to CCR.


facility_name: ACH Child and Family Services

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

raw_content: During the time of review a child was being restrained in front of another child and the child that was asked to help was attempting to take off the other child's shirt while 3 caregivers/staff were present.

Correction Narrative: Compliance was met by the operation proving a peer-to-peer support training to RTC staff on 10/09/2024. The training included when it might be appropriate to encourage peer-to-peer support and when it would not be appropriate. It was emphasized that peer to peer support is not appropriate when a client is dysregulated. RTC facility will not bring any client in to help with another client during a behavioral episode. Attendance Training log was provided with names and signatures of RTC Staff.


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 time of review a child was woken up during nighttime hours to help assist with another child in care that was being unmanageable when 3 staff/caregivers were present.


facility_name: The Residence By Infinity Elite II

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

raw_content:
During a review conducted on April 9, 2026 it was determined that:
(1)	the Administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
-	Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Correction Narrative: An HM extension was approved effective April 9, 2026.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is October 10, 2026.


facility_name: Inspirational Hope House

raw_content: Operation staff allowed a child in care to render first aid to another child in care.

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:
The operation submitted the following corrective action plan: Training will be provided to staff on not allowing residents to assist with first aide or other duties that are required by direct care staff.

A training was conducted between 04/27/2026-04/28/2026. All staff participated in the training. Staff certificates and a training roster were received and reviewed.


facility_name: El Paso Center for Children Emergency Shelter

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

raw_content: A staff members Annual Normalcy Training was 8 months late.

Category: Training and Professional Development

Correction Narrative:
Correction action plan
748.930 (b) (3) Annual Training  Caregivers must have 1 hour normalcy training.
The Emergency shelter will follow the following procedures:
1.	Staff Silviana Mullar will complete notmacly training. The training was completed on 11/25/2025.
2.	Program Director Beatriz Marin-Olivarez will ensure that all staff take their annual training on time.
3.	A calendar invite will be sent to all staff when annual training is due, and the list and name of the training will be included.
4.	Staff will have a log with all annual trainings and will mark out which trainings were completed to ensure all trainings are completed promptly.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: On the day of the incident only 1 staff member was on shift  with 4 youth in care with a level of specialized care. 1 youth was inside with the staff member, while the other 2 youth in care were outside alone unsupervised, which led to them leaving to the pond area to smoke.

Correction Narrative: RCCL Inspector conducted a face to face follow-up inspection to the operation. RCCL Inspector interviewed and spoke with the Director Roxana Escudero regarding the follow-up Inspection. The operation has implemented the following: The have reduced the number of children admitted into the program not to exceed 5 children in care at one time. There is always 2 staff members per shift. There is al on-call supervisor/ case manager to assist or back-up staff if needed.


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

raw_content: After reviewing the observation records for the child in care, the records indicate that the child in care on 8/17/23 at 9:10 PM was in the dining room, when the child in care was actually inside the kitchen via video footage accessing the unlocked medication.

Correction Narrative: Program manager Roxana Escudero will train the staff on operation responsibilities to address citation 748.151 on completing true and accurate records by October 30.


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

raw_content: A 17-year-old child in care was unsupervised by a caregiver and was able to obtain and ingest a large amount of an over-the-counter medication.

Correction Narrative:
Program Manager Roxana Escudero will review and ensure the children's right to be free of abuse and neglect minimum standard with shelter staff by October 30.
6.	Shelter staff must complete the abuse and neglect training provided by the DFPS system by November 6.
The alleged perpetrator (Staff member) was terminated on 10/19/23.


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

raw_content: A staff member did not provide the level of supervision to be aware of a child in care opening a window and climbing into the kitchen to have access to the medication cabinet and in digesting the medication.

Correction Narrative: 5.	Program Manager Roxana Escudero will ensure and review with direct care workers how to be vigilant with youth in care to be aware of each child's ongoing activity, safety, and whereabouts.


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

raw_content: A staff member left a medication cabinet unlocked in the kitchen and accessible to a child in care.

Correction Narrative:
Shelter staff will receive one-hour training on Minimum Standards Psychotropic medication procedure on October 27, 2023.
Shelter Staff must complete the Psychotropic medication training provided by DFPS by November 6.


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

raw_content: After a review of 3 different prescribed medications to a child in care. The prescribed medication logs did not provide a reason why the medications were being prescribed for.

Correction Narrative:
1.	Upper Management will audit on a daily basis the updated medication record to make sure medication records are complete.
2.	All Emergency shelter employees will check routinely on a daily basis for medication record completeness, step by step to reduce error.
3.	All emergency shelter staff are re-trained on medication regulations on August 28, 2023.
4.	All Emergency shelter employees will take monthly training refreshers to ensure all employees are taking the proper steps to be complying.


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

raw_content: A child in care was not taking their medications as prescribed.

Correction Narrative:
The correction action plan for the emergency shelter is as follow:
1.	Program manager will ensure all emergency shelter staff members are trained and maintain proper medical documentation.
2.	Long sleeve is not going to be allowed when administrating medication.
3.	Youth will be provided with the medication inside the medication cup.
4.	Youth will be required to open their mouths after taking medication.
5.	Shelter staff will ensure all medication has been swallowed and not being cheek.


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

raw_content: During the walkthrough of the inspection, there were two expired items (3/14/23) and one unlabeled prodcut (no expiration date on it).


Standard Number / Description: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

Deficiency Narrative: On the day of the incident only 1 staff member was on shift  with 4 youth in care with a level of specialized care. 1 youth was inside with the staff member, while the other 2 youth in care were outside alone unsupervised, which led to them leaving to the pond area to smoke.


summary: 748.455(a)(2) - Unauthorized AbsenceDebrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies

raw_content: The unauthorized debriefing did not include the trauma informed strategies a child can use to avoid future unauthorized absences and how the operation can support those strategies.

Correction Narrative:
As of 01/20/2023, the El Paso Center for Children will ensure that staff is trained on unauthorized absence-debrief trauma-informed strategies the child can use to avoid future unauthorized absences and how the operation can support strategies.
1.)	Once a youth returns to the shelter from an unauthorized absence, the shelter staff will conduct a debriefing with the youth as soon as possible. The debriefing must be done no later than 24 hours after the child returns to the shelter. The following will be discussed with the youth.
a.	The circumstances that led to the child's unauthorized absence.
b.	The trauma-informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies.
c.	The child's condition means their health and state of mind.
d.	What occurred while the child was away from the shelter, including:
i.	Where the youth went.
ii.	Who was with the youth.
iii.	The youth's activities.
iv.	Any other information that may be relevant to the child's health and safety.
2.)	The shelter will allow the child to return to their routine activities, and will exclude any activity that the caregiver determines would be inappropriate because of the child's condition following the unauthorized absence or something that occurred during the unauthorized absence.
3.)	The debriefing will be documented as a case note in the child's record, including any routine activity that would be inappropriate for the child to return to the shelter and the explanation for why the activity is inappropriate.
4.)	A template will be created for shelter staff to follow.


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

raw_content:
During a walk-through of the oeration, one of the Boys Restrooms was observed with insects.

Follow-up was conducted on 11/3/2022. The restroom is still beinf worked upon. Should be completed by 11/17/2022.

Correction Narrative: The restroom has been completely remodeled and is now being used.


raw_content: A staff member shut the door to the youth's room to call emergency services instead of assessing the youth for an injury.

Correction Narrative:
As of 12/16/2022, the El Paso Center for Children will ensure that staff is trained on prudent judgment, and self-control in the presence of children and when performing assigned responsibilities.
1.)	Shelter staff will always carry with them a fanny pack that will have the shelter's cell phone, cordless phone, shelter keys, and emergency numbers.
2.)	Having the phones on hand, staff can assess the youth and, in an emergency, can call for help. This will prevent the staff from leaving the youth unattended.


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: On the day of the incident, the youth care worker was caring for 7 children alone.

Correction Narrative:
As of 10/20/2022, the El Paso Center for Children will ensure that staff is trained on the ratio of a single caregiver may care for five children if at least one child in the group requires treatment services, or eight children if none of the children in the group require treatment services. The shelter does not serve youth under 11, therefore children younger than five years old count as two children. Staff was trained on ratio on 10/22/2022.
1.)	The shelter will have two staff during the day and evening when there is a youth with treatment services.
2.)	If the shelter has more than five youths and one has treatment services: if the staff has an emergency staff will not leave until the staff on call or another staff comes in to relieve the staff.


raw_content: Staff advised youths that were planning to run away to avoid using the windows to prevent property damage and use the main entrance instead.

Correction Narrative:
As of 9/16/2022, the El Paso Center for Children will ensure that staff is trained on defining and demonstrating competency, prudent judgment, and self-control in the presence of children and when performing assigned tasks.
1.)	Staff will be trained on demonstrating competency, prudent judgment, and self-control on 09/23/2022.
2.)	Staff will talk to the youth once they know youth are planning to leave the shelter.
3.)	Staff will let the youth know that it is not safe to leave the shelter. A shelter is a safe place with food, water, and shelter.
4.)	Staff will contact the youth's CPS worker or legal guardian to inform them about the youth's plans. Try to have them talk to the youth.


raw_content: During a walk-through of the oeration, one of the Boys Restrooms was observed with insects.

Standard Number / Description: 748.3301(h) - Physical Site-The building must be free of rodents and insects


Correction Narrative:
As of 8/5/2021, the El Paso Center for Children will ensure that staff is trained on defining and demonstrating competency, prudent judgment, self-control in the presence of children and when performing assigned tasks.
1.)	As of 05/26/2021, Mr. Finlayson was not left alone during his shift. A second staff member was added to the night shift to work with Mr. Finlayson.
2.)	Staff will be trained on demonstrating competency, prudent judgment, and self-control on 8/10/2021.
3.)	The Program Director will conduct random camera checks weekly to ensure the safety of the youth.
4.)	Ms. Lorena Calvillo's investigation focused on potential lack of prudent judgment.   Based on the exit interview with Ms. Calvillo found that  Mr. Finlayson did not show prudent judgment and self-control in the presence of the youth in his care and required that a corrective action plan be submitted by the agency by 8/05/2021. Based on these findings, the relationship between El Paso Center for Children and Mr. Finlayson has been terminated.


facility_name: Redicare

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

raw_content: The children were inadequately supervised and led to an altercation.


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

raw_content: A child in care was performing restraints on other children.


facility_name: Westlake House LLC

raw_content: Caregiver violated operation's policies.

Correction Narrative:
Operation provided the evidence that support the standard cited is now in compliance.
Operation has terminated the employee who violated policy and the operation will conduct the following tasks to ensure said deficiency does not reoccur:  1)
Westlake House will reissue a copy of the employee handbook to all staff by 04/29/2026.
(2)
All Westlake House staff will be retrained on the gift policy by 04/29/2026; and quarterly facilitated by Devonna Thompson, LCCA or current LCCA.
(3)
Westlake House will reissue a copy of the resident handbook to all current residents and will discuss Westlake House gift policy by 04/29/2026 and quarterly, facilitated by Devonna Thompson, LCCA or current LCCA.
(4)
Westlake House will continue to hold quarterly meetings with all staff and all residents regarding Westlake House gift policy.


facility_name: Devine Care Home RTC

raw_content: Staff member failed to intervene when two children in care that were engaged in a physical altercation.

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


facility_name: Horizon Heights Children's Home LLC

summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: One out of three child records reviewed did not have a completed suicide screening completed within 90 days of the last completed suicide screening.

Category: Organization and Administration

Correction Narrative: Follow-up by inspection.


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

raw_content: Caregivers failed to ensure that a child was given medication as prescribed.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: One out of three child records reviewed had a suicide screening completed five days after admission.


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

raw_content: One out of three staff records reviewed did not have a completed affidavit for review in the employee file.

Category: Personnel


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: One out of three staff records reviewed did not contain reference checks documented in the employee file.


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: Two out of the three staff records reviewed did not have education qualifications in the employee file.


facility_name: Keagans Residential Care Homes LLC.

summary: 748.705(b)(8) - Reasonable & prudent parent standard-must consider the outside supervision of the activity, if available and appropriate

Correction Narrative: Operations submitted a corrective action plan via email. Staff will be retrained on supervision and expectations. Staff involved is no longer employed. I attempted to speak to a child to ask questions regarding supervision. Child refuse to speak with RCCR. Owner Rhonesha was present I asked questions regarding supervision and corrective action plan, training date 2/19/26.


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

raw_content: During this investigation it was determined that supervision was not provided to two children and a staff member was not present to separate a fight at Keagan.

Correction Narrative: CAP operations submitted a plan of action to retrain staff on supervision. Staff involved is no longer employed.


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: Timely reporting for unauthorized absence was found to be past the required time frame.

Correction Narrative: The operation revised all serious incident report forms to include mandatory date and times. The operation designated an on call administrator who will verify and document licensing notification within the same timeframe.


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

raw_content: During the review of background checks, a staff who was let go on 8/18/2025 was still active on the operation's people list, and it is past the 7 day requirement.


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

raw_content: Medication administration records do not reflect the remaining amount, and none of the medication logs include a section to record the count.

Correction Narrative: Operations documentation Form 2993 Medication Log was evaluated, and physical count were conducted, and no concerns were noted.  The executive director conducts daily audits to ensure compliance is meet.  The operation has one completed example of a medication log with all applicable information.


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

raw_content: Medication logs were observed to include the initials of the staff who administered the medication but there's no other identifying information to determine who administered the medication. The operation denied having a separate document that includes the name, signature, and initials of staff who administer medication.

Correction Narrative: Operation will be using Form 2993 Medication Log as it has all required medication information.  Operation plans to use the form moving forward to stay in compliance with the minimum standards at all times. The executive director is responsible for ensuring compliance.  The operation also provided one completed example of a medication log with all applicable information. The LCCA/ ED or the case manager will check the medication logs at least twice weekly.


state: MN

facility_name: Aspen House

summary:
PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Document