summary: 745.8641 - Requirements during probation

raw_content:
Condition 1 was met.
Condition 2 was not met. The videos were not reviewed during the proper hours. There were not at least two visits per week for a minimum of two hours.
Condition 3 was met.
Condition 4 was met. Feedback was provided.
Condition 5 was met.
Condition 6 was not met. There was an EBI not documented.

Correction Narrative: The administrator sent an email stating that the Camp Worth Team will be reviewing the probation conditions weekly to ensure the conditions are being met. The quality assurance will also ensure the conditions are being met.


state: TX

facility_name: Camp Worth, LLC

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

raw_content: There was an EBI conducted an and documentation was  not completed.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: The administrator sent an email that the administrator will review videos and incident reports and ensure that all EBI documentations are completed and placed in the child's file. Disciplinary action will be implemented if it is determined that the proper interventions were not utilized or if the documentation was not completed in a timely 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: There were two medications reviewed where the medication count was incorrect.

Category: Medication

Standard Risk Level: Medium High

Correction Narrative: There will be QA checks on medication records at a minimum of three times a week per child to ensure compliance.


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

raw_content: One out of two children files reviewed did not document the reason for the medication for three medications and the time or initials for one day.


raw_content:
Condition 1 was met.

Condition 2 was met. Feedback was provided.

Condition 3 was met. Posttest will be completed by November 30.

Condition 4 was not met. The service plan and date of the service plan were not documented on the staffs monthly conference.

Condition 5 was met.  Feedback was provided.

Condition 6 was met.

Standard Number / Description: 745.8641 - Requirements during probation

Standard Risk Level: High

Correction Narrative: For Condition 4, the form was updated to include the service plan and date of the service plan that the treatment director discussed with the staff.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: An incident where a child swallowed an item and needed to be hospitalized was not reported within the proper time frame.

Correction Narrative: Inspector spoke with administrator. The process for reporting all incidents has been updated to include that the administrator will review and sign all incidents. Prior to documenting the report caregivers and/or the Facility Supervisor will contact the Agency Administrator for guidance and debriefing.


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

raw_content: A child who has a history of self-harm was unsupervised in the kitchen looking for items that could have caused harm.

Correction Narrative: Inspector met with administrator. The staff review the Daily Information Report before the start of their shift to review the information in regard to each youth's supervision requirements, as well as which youth each caregiver is responsible for and any other pertinent information involving the previous shift. A copy of the form was provided to Inspector. The staff involved in the incident is no longer employed.


summary: 745.8641 - Requirements during evaluation or probation

raw_content:
Condition 1 was met.

Condition 2 was met.

Condition 3 was not met. Training information was not submitted to meet the condition.

Condition 4 was met. Feedback was provided.

Condition 5 was met.  Feedback was provided.

Condition 6 was met.

Correction Narrative: The administrator sent an email with the condition 3 updated and corrections made.


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

raw_content: A child's initial service plan has the name and electronic signature of an individual that did not participate in the service plan development for a child in care.

Correction Narrative:
The operation has requested an administrative review.

RCCR Inspector Lisa Sanchez received an email from administrator stating that the operation will ask anyone not in person if they can print name on service plan. They will also follow-up with an email to confirm. They will then print out confirmation and attach to the service plan.


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: One out of two employee files reviewed did not provide the high school or equivalate documentation.

Correction Narrative: RCCR Inspector recived an email from the administrator with a copy of the staff's transcript documenting her graduation date. Also, administrator stated that the compliance director will have a checklist to ensure all staff will have the required documentation before starting employment.


summary: 745.635(2) - AP Background check determination - If ineligible then you must immediately remove subject from operation and confirm to CBCU receipt of notice letter

raw_content: A staff person was present at the operation, after notification that they were ineligible.

Correction Narrative: Staff member is not present at operation. The safety plan is being followed. The background check has been run.


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

raw_content: The service plan was not signed by the child in care.

Standard Risk Level: Low

Correction Narrative: The operation will create a signature page and have all who participate, sign the page. The signature page will also be sent to any case worker or therapist via ZOOM to sign. The operation will document if a child refuses to sign.


summary: 748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it

raw_content: The PLSP did not sign the child's service plan.

Correction Narrative: The operation will create a signature page and have all who participate, sign the page. The signature page will also be sent to any case worker or therapist via ZOOM to sign.


raw_content:
Condition 1 was met. Feedback will be provided to operation.

Condition 2 was not met. No visits were documented for the first week. The week for video observations was for week one was 2 hours. Week 2 for video observation was 2 hours and 40 minutes. Week 3 for video observation was 30 minutes. The documentation was missing the staff observed. Also, the master log was not signed by the LCCA or approved designed.

Condition 3 was met. Feedback will be provided to operation.

Condition 4 was not met. There is a log of the meetings but there is no summary of the meetings and the issues discussed.

Condition 5 has been met.

Condition 6 was not met. There was 2 restraints reviewed. There was only 1 reviewed for documentation by the operation. There was no documentation where the staff and children were debriefed.

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

Correction Narrative: All the conditions were met.


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

raw_content: The EBI documentation does not document the conversation or the child's reaction.

Category: Emergency Behavior Intervention

Standard Risk Level: Medium Low

Correction Narrative: The administrator has updated the EBI review form to document the child's reaction after the EBI. A copy was sent to RCCR.


summary: 748.2855(b) - EBI Documentation-Supervisors of caregivers involved in EBI must document review of the intervention within 72 hours of the incident

raw_content: A supervisor did not document their review of the use of the intervention.

Correction Narrative: The administrator has updated the EBI review form to document the staff's involvement in EBI. A copy was sent to RCCR.


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 was arrested on 8/22. The incident was not reported for 42 hours later.

Corrected at Inspection: Yes


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

raw_content: A caregiver was observed with her arm around a child's neck while conducting a restraint.

Correction Narrative: Staff no longer employed. EBI training has been updated.


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

raw_content: A caregiver immediately put a child in a restraint without using any de-escalation method with the child.

Correction Narrative: Staff no longer employed. EBI training has been updated. There has been no restraints conducted recently.


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

raw_content: The caregiver restrained a child in the prone position.


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

raw_content: A caregiver was observed putting her entire body weight on a child's torso while the child was being restrained.


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: The caregivers did not document or inform management that multiple EBI restraints were conducted with a child in care.


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: The operation did not notify the parents of a child in care, that a restraint was conducted.

Correction Narrative: A new procedure has been put in place. The operation has a staff member responsible for sending the notice to the parent.


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: The caregivers did not provide privacy for a child that was being restrained and allowed two children to observe the incident.


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

raw_content: A child that was having a behavioral crisis and destroying property and breaking windows.  The caregivers did not implement a restraint to ensure the child didnt injure themselves.  The child did have to seek medical treatment.

Correction Narrative: Inspector spoke with administrator. Staff have been trained with the updated EBI curriculum. It was discussed that situations are a part of the new curriculum to discuss appropriate ways to handle the situations. Inspector also interviewed staff about the training received and techniques learned.


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

raw_content: Multiple staff members were informed of an allegation of a staff member hitting a child and did not report the allegation.

Correction Narrative: Staff were trained on reporting. Updated job descriptions were provided to the staff.


raw_content: A restraint was conducted on a child and the child's parent/case worker was not informed.

Standard Number / Description: 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

Correction Narrative: A person has been designed to be responsible to contact a child's parent/case worker of any EBIs conducted.


Standard Number / Description: 748.2855(b) - EBI Documentation-Supervisors of caregivers involved in EBI must document review of the intervention within 72 hours of the incident

Deficiency Narrative: A supervisor did not document their review of the use of the intervention.

Correction Narrative: A new system has been developed to ensure that all EBI documentations will be completed and documented in the child's record.


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

raw_content: A staff member did not use any de-escalation methods with a youth in care.

Correction Narrative: Staff is no longer employed with the operation.


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

raw_content: A youth in care was injured in the face during an attempt of a restraint by a staff member.


summary: 748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training

raw_content: The training certificate does not document the trainer's qualification for the staff's EBI training.

Correction Narrative: The operation has a quality assurance person to review training certificates. Certificates were updated for proper documentation.


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

raw_content: 3 of 3 children files reviewed did not have allergy information documented on the exterior of the file.

Category: Reports and Record Keeping

Correction Narrative: The director sent an email stating that they are using red labels on the front of their files to note any allergy information.


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

raw_content: Of the 6 incident reports reviewed, 4 were missing informaiton required in 748.311(3) and 3 were msising informaiton required in 748.311(1)

Correction Narrative: The director sent a copy of the updated report to include all the required information.


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

raw_content: The operation reported a video was not available due to IT issues. This statement was not true.

Correction Narrative: RCCR Inspector spoke with designee and administrator. The internet provider system has been changed to a new company and updating the wiring system. The operation will be adding 4 cameras. This will assist in providing any requested video.  Video system only keeps videos for 30 days.


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

raw_content: After a child was escalated. A caregiver was responsible for attempting to fight a child in care. The caregiver had to be restraint by another caregiver.

Correction Narrative: RCCR Inspector spoke with administrator and designee. The staff member is no longer here. The background check has been inactive. Training will be provided for other staff on fire safety and fire extinguishers. This will also include therapist. The training will tale place by 11/30/22.


raw_content: The staff engaged in aggressive behavior with the security guard in front of a child in care and made the child feel unsafe.

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 staff member is no longer employed with the operation. Director has discussed with other staff how to interact with youth when in the community. The designee has requested an admin review due to a disagreement on the citation.


summary: 748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies

raw_content: The EBI documentation did not include any details on the de-escalation techniques utilized prior to the restraint. The space for this on the form is blank

Correction Narrative: The operation sent updated forms that have prompts and spaces for all information required in minimum standards. Additionally the operation sent a compliance letter detailing that all staff will receive additional EBI training with an emphasis on documentation. It also reads that new procedures have been put in place to help review EBI documentation such as the LCCA being notified immediately of any containment and two facility supervisors who will ensure that containments are done properly and all the minimum standards are followed.


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

raw_content: The EBI documentation did not include any details of what occurred prior to the restraint. Further the caregiver who performed the restraint could not recall what the situation was prior to the restraint.


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

raw_content: The EBI report did not document any post discussion with the child

Correction Narrative: The operation sent updated forms that have prompts and spaces for all information required in minimum standards and an additional form to document the post discussion with the child. Additionally the operation sent a compliance letter detailing that all staff will receive additional EBI training with an emphasis on documentation. It also reads that new procedures have been put in place to help review EBI documentation such as the LCCA being notified immediately of any containment and two facility supervisors who will ensure that containments are done properly and all the minimum standards are followed.


summary: 748.453(a)(3) - Unauthorized Absence  Annual summary log must include how long the child was gone or if the child did not return

raw_content: The unauthorized log does not document how long the child was gone, the the name of the caregiver responsible for the child at the time the child's absence, the intake report number, and whether law enforcement was contacted, including the name of any law enforcement agency that was contacted and the number of the police report.

Correction Narrative: The CEO sent a copy of the updated log to include all the required information for any unauthorized absences.


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: The initial service plan was not in the youth's file within 30 days.

Correction Narrative: The CEO sent an email stating that all the agency will label the records, files, and logs. The agency will make sure that staff who have access to the files know and can properly identify all logs/records properly.


summary: 748.461(1) - Unauthorized Absence-Triggered Review must include review of childs records abt previous unauth absences, including previous debriefings

raw_content: The trigger review did not document the previous unauthorized absences, including previous debriefings,  alternatives to minimize the unauthorized absences, and a written plan to reduce the unauthorized absences of the child.

Correction Narrative: The CEO sent an email documenting that the it has been discussed with the staff how to document a trigger review for a youth. The trigger review for the youth reviewed was not completed due to the youth not returning to the operation. An admin review will be requested.


summary: 748.125(b) - All employees and caregivers must be aware of and follow your operation's policies and procedures

raw_content: A staff member fell asleep during the her shift and supervising children.

Correction Narrative: The staff member is no longer employed by the operation.


summary: 748.361(b) - Personnel records-Archived records maintained at the operation and/or in a designated location

raw_content: A staff file was unavailable for review.

Correction Narrative: Administrator sent an email that all active and inactive employee records will be maintained in the administrative office within a locked file room. Inactive files will be maintained for one year following an employee's last day of employment or until any investigation involving the employee is resolved, whichever is longer. The staff will not be left alone to have the opportunity to take any files.


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: A staff member's last day of employment was 3/15/22. However, the background check was inactive on 4/21/22.

Correction Narrative: Administrator sent an email stating that the LCCA will be notified of all employee terminations and inactive them ASAP. Once a week, the LCCA will review all employees with the operation and inactive their status if they are no longer associated with the operation.


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

raw_content: RCCR Investigator requested the footage for certain days on multiple occasions and it was never obtained.  The footage was for different days that was regarding the investigation.

Correction Narrative: Administrator sent an email stated that the operation will will ensure active and archived records are available for review when requested by CCR. The operation will confirm all requested by email with the administrator.


summary: 748.3161(c) - Heating Devices-Must ensure children do not have access to floor and wall furnace grates, steam and hot water pipes, and electric space heaters

raw_content: The cord to a space heater plugged in the hallway caused a child to trip resulting in an injury requiring treatment by a medical professional.

Correction Narrative: RCCR Inspector Lisa Sanchez observed the hall. There are no heaters. They have been removed from the home. They will not be used in the houses. If any items are used with cords, they will be close to the wall where they will not be a tripping hazard. This has been addressed with staff.


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

raw_content: A child that has a history of running away and was required to be in  visual sight of a caregiver was allowed out of sight of caregivers which allowed him to run away twice within two days.

Correction Narrative:
RCCR Inspector met with administrator. All staff who are supervising youth have been informed of the supervision plan required for youth. Staff are ensured that they understand the requirements before the duties are assigned.

The operation stated that they plan to investigate the matter, if they find that the employee was not truthful in their statements the employee will be terminated. Meanwhile they will the monitoring with the employee concerning the line of sight and include a review of protocols regarding communication and documentation that is timely, accurate and without hesitation to ensure the safety, well-being of the youth involved and the compliance we are governed to adhere to. the plan will be completed on or before June 7, 2022.


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

raw_content: Two of the children's service plans document a supervision of  1:1 during awake hours. There was only one staff with the two children.

Correction Narrative: Service plans for the youth were reviewed and updated.


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: Caregiver hit a child in the head and head butted a child because the child was not doing homework.

Correction Narrative: Staff member is no longer employed.


summary: 748.535(2)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The administrator did not ensure the child's needs were met by having a staff member who was a risk to children continue to provide care.

Correction Narrative: The administrator reviewed the employment history of the staff to determine staff responsibilities and limits.


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

raw_content: A caregiver was involved in an altercation with a child in care and did not provide a safe environment for other children in the area.


summary: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

raw_content: The caregiver placed a child in a choke hold resulting in the child not being able to breath and caused discomfort.


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

raw_content: A caregiver called a child names and taunted a child instead of de-escalating the situation which resulted in an inappropriate restraint hold.

Correction Narrative: Staff member is no longer employed..


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 hit several times and put in chokehold by a caregiver resulting in the child needing medical treatment.


summary: 748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest

raw_content: A staff member denied youth in care the right to make phone calls.


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

raw_content: A staff member used profane language and yelled at youth in care.

Correction Narrative: Inspector conducted inspection. The staff member is no longer employed. Interviewed staff and youth on interaction of youth.


summary: 748.903(c)(3) - Pre-service training for emergency behavior intervention-Includes safe restraint techniques and procedures appropriate for child's age and weight

raw_content: A staff member did not have the complete training on restraints that are used in the operation.

Correction Narrative: Staff completed training on 1/21/22.


raw_content: The service plan indicates that a child in care requires a 2:1 supervision ratio and that was not followed.

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

Correction Narrative: Staff member is no longer employed. Other staff members took training on developing service plans on 1/21/22. Also, how to implement service plans.


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

raw_content: A staff member shut a door on a child as an attempt to control a child's behavior. The child's de-escalation method of supervised separation was not implemented.

Correction Narrative: Staff member is no longer employed with the operation. Inspector spoke to children at inspection to ensure proper discipline is being used with current employees.


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

raw_content: The service plan for a child in care was not developed specifically for that individual. There were several different names listed throughout the service plan indicating that the service plan was copied and pasted.


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

raw_content: One out of three medication logs that were reviewed did not have the time the medication was administered.

Correction Narrative: Administrator reviewed with the two staff the policy on documenting medication. Discipline action was taking with the staff.


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

raw_content: A caregiver admitted to sitting on a couch and placing his arm across the chest of a child in care in order to keep him from getting up, prior to de-escalating the situation.

Correction Narrative: The caregiver is no longer employed with the operation.


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

raw_content: A caregiver admitted to getting very close to a childs face and yelling in order to intimidate him.


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

raw_content: There was not a name or signatures on a childs medication log for the dates of March 5 through 11, 2021.

Correction Narrative: Administrator sent email. The person who was response to review medication logs is no longer with the operation. The process has been reviewed with the staff and will be reviewed to ensure the name and signature is on all medication logs.


summary: 748.1547(2) - Vision and hearing examination-If a child in care needs an examination, ensure the professional and medical recommendations are carried out

raw_content: A child had a vision appointment due on 11/16/2020 but did not attend.

Correction Narrative: Administrator sent email documenting that another appointment has been re-scheduled for the youth for May 18, 2021. Administrator will ensure that youth attends appointment. Youth did not make appointment due to COVID and staff did not re-schedule. Staff is no longer with operation.


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

raw_content: There were fourteen people who were still active but were no longer associated with the operation.

Correction Narrative: Administrator sent an email stated that all names have been inactive.


raw_content: The staff member used a restraint instead of using the youth's preferred de-escalation method.

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

Correction Narrative: Inspector spoke with administrator during inspection. The staff were re-trained in EBI techniques and appropriated methods. Several of the staff involved are no longer employed.


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

raw_content: A staff member used a restraint hold on a youth that was not warranted.

Correction Narrative: Inspector spoke with administrator during inspection. The staff was re-trained concerning discipline and methods of de-escalation. The staff is not working in the same home at this time.


facility_name: Amazing Grace Child and Family Services

summary: 745.651(2)(A) - Background Check Validation  Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content:
Backgrounds were last validated on 11/16/21.
This was corrected at inspection.


facility_name: Fred and Mabel Parks Youth Ranch

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

raw_content:
During the investigation it was discovered that when the fight broke out between four residents. The direct care staff present was observed on video surveillance walking up to
the two different fights while on the phone and did not try to deescalate or intervene the children from fighting.

Correction Narrative: On 3/24/2026 Inspector interviewed children in care at the operation and verified that staff are present and able to intervein when an emergency happens at the operation. The children interviewed stated that they felt safe at the operation.


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

raw_content: On March 1, 2026, the childcare ratio was at the operation was 1 one direct care staff to ten children at the operation. One direct care staff left with one child leaving the operation not fully covered.

Correction Narrative: On 3/24/2026 Inspector interviewed children in care at the operation and verified that the operation has staff available on every shift. Inspector was also able to verify the schedule for staffing at the operation.


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

raw_content: During an investigation review, it was reported that a staff member engaged a child in care in an inappropriate conversation unrelated to the child's safety, care, or supervision. The staff member reportedly asked the child whether her boyfriend believed she was engaging in sexual activity. Additionally, the staff member discussed unverified information regarding another staff member, which included spreading rumors. The staff member's actions demonstrated a lack of prudent judgment by engaging the child in adult and personal subject matter and by involving the child in staff-related issues.

Correction Narrative:
A copy of the agenda and sign in sheet for 01/24 and 01/27/26 for the Handle With Care refresher with 21 staff signatures was received by email on 01/29/26.
A corrective action plan received on 01/27/26 from the administrator identified the following plan: Shelter administrator will ensure that all staff members maintain appropriate professional boundaries, protect children from exposure to adult or personal subject matter, uphold confidentiality, and provide a safe, respectful, and developmentally appropriate environment for all children in care. During the Handle with care Refresher training held on 1/24 and 1/27/26, administrator and executive director reinforced expectations related to professional conduct. Staff received guidance on maintaining boundaries, strict prohibition of discussing sexual, personal, or adult topics with children, and the importance of confidentiality including the prohibition of gossip or rumor-spreading, staff were also reminded of child's rights, and that children must not be involved in staff conflicts, personal opinions, or workplace matters. The staff member involved was terminated on 12/01/25. Admin and staff supervisors will monitor staff on duty to provide feedback necessary to discuss and report violation of Code of Conduct and Employee professionalism policy as soon as they become aware of it. Shelter staff will update the employee reference check to include new screening questions for future violations.


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

raw_content: During an investigation transfer review images taken of the restroom show the area to be unclean.

Correction Narrative:
Received by email a sign in sheet with 21 signatures, an agenda related to shift walk/throughs on 01/24 and 01/27/26 and the walk-through shift task and chore list document.

A corrective action plan was received on 01/27//26 from the administrator with the following: Supervisory walkthrough will be completed before and after every shift to ensure the facility is clean and in compliance with physical site standards; effective immediately.


raw_content: Staff engaged in verbal altercation at the facility in presence of children. Multiple staff and children interviewed confirmed the story. Multiple children interviewed confirmed hearing staff using inappropriate words against the other staff during the verbal altercation. Disciplinary action was taken by the operation against staff involved in the altercation.

Correction Narrative: Children in care denied witnessing or hearing staff engage in a verbal altercation.


raw_content: Two of three children reported observing staff asleep while on duty.

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

Correction Narrative: Children in care denied witnessing staff sleeping.


raw_content: 5 out of 6 youth interviewed reported staff yelled at youth in care.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative: As a result of the investigation, ALL Staff will be held in December regarding TBRI aligned correction principles and techniques.


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

raw_content: A child who had previously eloped, ran away again and it was not reported timely.

Correction Narrative: Shelter administrator will ensure that all unauthorized absences are documented accurately and reported to the necessary authorities in the required timeframe as required by minimum standards.


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

raw_content: Several residents advising that staff do not check on them while they are in their bedrooms for extended periods of time.

Correction Narrative:
04/16/25 -PYR's Administrative and Case management team will ensure all resident records/ documentation is completed accurately as it pertains to each individual child in our care.

05/14- A physical follow up was conducted at the operation. Staff and Children's files were in compliance.


raw_content:
The unauthorized absence log did not contain all components per minimum standards. It also indicated conflicting information on the time she returned.

The 72-hour plan did not include how supervision will be increased due to high risk behaviors identified.

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

Correction Narrative:
The facility responded: PYR Administrator will ensure that in the event an unauthorized absence occurs. The Unauthorized Absence Log will be accurately completed, with all required information per standard 748.453.

PYR Administrator along with case management will review all admission assessment and 72-hour services plan to ensure all required information is accurately and appropriately documented to meet each resident's specific needs.

This corrective action plan will be effective immediately and will be on-going


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: The intake report was not submitted within 24 hours of the incident.

Correction Narrative: The operation stated in their Corrective Action Plan that the Administrator assigned to the operation will provide additional oversight for reviewing SIR's to ensure that all time stamps are reflective and indicate the operation's reporting time frames in accordance with the standard.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: Staff failed to report to licensing once aware of the child's self-harm.

Correction Narrative: The operation emailed a Corrective plan of action stating that staff will ensure all life-threatening injuries are evaluated and treated by a medical professional. PYR Administrator will notify Licensing no later than 24 hours after serious incident occurs.


raw_content: During the walk through of the shower room on the boys wing of the building, i observed mold and excessive build up on the tile, This was also observed in the girls wing as well.

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


raw_content: A serious incident was not reported to licensing following the alleged incident where law enforcement responded.

Standard Number / Description: 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.

Correction Narrative:
On 08/13/2024M, The following email was received from the operation. The operation will continue to follow the HHSC Minimum Standards for General Residential Operations, as they pertain to Serious Incident Reporting including definitions and contract guidelines. The operation will provide an agency Memo to all staff to serve as a Refresher for the Serious Incident Report guidelines; by September 1, 2024.

An administrative review will be submitted for the Operation by August 16, 2024.


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: A child did not receive one of his medications for 7 days due to a lapse in his prescription being refilled.

Correction Narrative: On 6/4 I received an email from the Administrator with a photo of the child's medication. The medication label stated they filled the medication on the 29th; however, they did not receive the medication delivery until June 3rd after 5 pm. The  Administrator called Star health to ensure the pharmacy was still open due to they had not be successful in reaching them.


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

raw_content: A child in care missed two months of physical therapy that was recommended by a health provider.

Correction Narrative:
On 02/20/2024 an email was received from administrator Jada Bratton with compliance stating the operation will adhere to the Minimum Standards for a child in care and provide backup assistance in the event that an incident such as this occurs in the future.
The operation will use DFPS Resources such as the Local Permanency Worker, or Transporter, in the event that the current staffing model is compromised, or submit a variance request to the standard if no assistance is provided.
The operation will continue to maintain their admission criteria for youth who present medical needs outside the scope of services provided.

On 3/4/2024 I Inspector Jakobi Conducted a PPM HM inspection to follow up with this concern. 2 child files were reviewed regarding medical documentation and the documents proved no concerns with children attending medical appointments, as no medical appointments or follow ups were missed.


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

raw_content: Based on staff interviews it was confirmed that a staff member was yelling and using inappropriate language towards a resident of the operation during a verbal altercation.

Correction Narrative:
The operation is in the process of revising the
Resident Grievance policy to include this standard.
In the event that a resident overhears or is the
Recipient of said language, the resident will
Maintain the right to submit a Grievance via the
Internal Grievance Policy protocol. A staff retraining will also be conducted at the operation July 24th and 26th regarding best practice to de escalate situations.An Amendment was made to the previously scheduled All-Staff date of July 20th, due to unforeseen circumstances. The new dates for All-Staff are July 26th and July 29th.* Staff members who are unable to attend in person will meet with Shelter Administrator 1:1. Staff members will receive electronic copies of policy changes by August 4, 2023.
All Staff Agenda to include: Risk Management and Professional Boundaries (Hand out Provided)
Supervision  Auditory Vs Visual (prohibited use of Headphones, Earbuds)
Resident Grievance Policy (Resident Meeting TBD return from Camp 7.26.23)
Staff Language
Cell Phone Policy & Normalcy Outings
Contraband Red Flags, Company Policy on Tobacco & E-Cigarettes
Transportation  Changes made to Training Policy (Weapons, Contraband, Professional Boundaries, Reckless Driving), AZUGA Monitoring System


summary: 748.705(b)(7) - Reasonable & prudent parent standard-must consider the surrounding circumstances, hazards, and risks of the activity

raw_content: Based on the information gathered, a body piercing was done with a piercing gun by an unlicensed or certified professional at the housing facility of the operation.

Correction Narrative: An email was sent from the operation stating they have conducted a staff meeting to retrain staff on July 20 and July 26th where Professional Boundaries were discussed. Moving forward the operation will obtain consent from the necessary parties as well as provide reimbursement to use a licensed professional.


raw_content: Based on Investigation review it was noted in interviews that staff left children in care unattended for a brief moment. During this time residents took the opportunity to get in a car with an unknown individual to leave the facility.

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

Correction Narrative: AN emailed corrective action plan was emailed for the operation stating that: Immediately and continually Parks Youth Ranch staff will continue to follow the reasonable and prudent parent standard while understanding which children they are assigned to and maintaining an understanding of activities and interactions occurring between residents.


raw_content: A child in care and staff member stated that they heard the same staff member use profane language in the presence of other children in care.

Standard Number / Description: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Correction Narrative: The operation submitted the following correction: Staff were counseled Tuesday March 22, 2022 and Wednesday March 23, 2022 regarding the deficiency and context surrounding the deficiency. All staff will participate in a TBRI Refresher to revisit Empowerment Principles scheduled for April 1, titled See The Need, created by the Karen Purvis Institute of Child Development. All training certificates were received via email for all staff.


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

raw_content: A child in care missed three of their medications for three days and there is no medication error documentation.


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

raw_content: During a walk through of the facility I observed the freezer at 10 degrees.

Correction Narrative: During a HM inspection on 10/21/2021 all thermometers were present in the refrigerators and freezers at the operation. The freezers were observed as set at 0 degrees.


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

raw_content: The serious incidents observed did not have the physical address, telephone number or identifying information of the staff involved documented on the form.

Correction Narrative: The Electronic Database System, Kaleidacare, will be revised to include the Physical Location (as it has the Operation's Name and Logo). The Locations of the incident report include location on-site (example: Girls Unit, Boys Unit, Recreation Center). The section includes a Physical Address requirement now.


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: There is no documentation in 5 staff file of the staff being qualified with a high school diploma, or documentation of equivalence.

Category: Personnel

Correction Narrative: Requests were made on 9/15/2021 for three staff files, two of the files reviewed belonged to the ED and a Professional Level Service Provider whose Degree was posted on the wall. All staff will be requested to provide additional copies for record retention.


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

raw_content: One child's file presented no indication that the child had a TB exam completed.

Correction Narrative: It was assessed that the operation acquired a homeless youth as a resident as apart of one of their contracts. It was noted that the operation admitted this child in February  and after he was discharged on the date of 5/24/2021 no longer requiring the operation to gather or maintain these documents. The discharge documentation was reviewed as proof.


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

raw_content: One child's file reports an inaccurate date of admission as 04/12/2021. Child was admitted in February 2021.

Correction Narrative: IT was assessed that the operation acquired a homeless youth as a resident as apart of one of their contracts. It was noted that the operation admitted this child in February  and after he was discharged on the date of 5/24/2021 no longer requiring the operation to gather or maintain these documents.


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

raw_content: One of four child files did not contain notification of the service plan meeting to the legal parent.

Category: Admission, Service Planning, Discharge


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

raw_content: A child in the care of the operation was not scheduled for a dentist appointment and never received a dental visit; it was offered a 2 months after admission.


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

raw_content: One child's file did not contain an initial service plan with an admission time frame ranging from 02/2021-05/2021.

Correction Narrative: This citation had been left pending from the original inspection. It was marked deficient and AR upheld as it was addressed during the AR process- Ms. Tristan noted in an email dated 10/25/21- We did not fulfill an Initial Service Plan before child came into DFPS Custody as we received much back and forth about his custody arrangement. I understand if that will lead to deficiency." She provided the completed service plan to reflect it was completed, but after the required timeframe. Steps will be taken in the future to complete all service plans in time, even if the child is not in DFPS custody.


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

raw_content: A in the care of the operation did not receive an medical examination initially; it was offered 2 months after admission.


summary: 748.1539(c) - Immunizations-Required immunizations must be completed by the date of admission or begin within 30 days after the date of admission

raw_content: One child's file does not indicate immunizations records were obtained nor a referral to the appropriate health care professionals to obtain the required immunizations.


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

raw_content: A caregiver was physically aggressive with a child in care. The incident was captured on video and there were other children in care that witnessed the incident.

Correction Narrative: It was noted that an email was sent regarding this deficiencies corrective action plan on 8/11/2021 stating that, A staff memo will be distributed to all staff on August 13, 2021 regarding the closure of Investigation #2749634. A TBRI Refresher training will be held on August 27, 2021 and August 28, 2021 regarding Correcting Principals - appropriate consequences and discipline. As proof A signed memo was also observed.


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

raw_content: A caregiver exchanged verbal extremities with a child in care, which included the caregiver grabbing and pushing a child aggressively.

Correction Narrative: It was noted that an email was sent regarding this deficiencies corrective action plan on 8/11/2021 stating that, A staff memo will be distributed to all staff on August 13, 2021 regarding the closure of Investigation #2749634. A TBRI Refresher training will be held on August 27, 2021 and August 28, 2021 regarding Correcting Principals - appropriate consequences and discipline. As proof A signed memo was also observed, as well as staff training documents.


facility_name: Discovery Practice Management

summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: Two child files did not include information related to 748.1337(b)(1)(E ), 748.1337(b)(1)(F ) or 748.1337(b)(1)(G ).

Correction Narrative:
On 3/9/2026 the operation submitted the following plan to mitigate risk:

In response to the deficiency cited under Standard 748.1337(b) regarding Initial Service Plan documentation, we(the operation) conducted a comprehensive review of all patient charts. All necessary corrections were completed as of Saturday, March 7th. To help prevent this issue from reoccurring, we are implementing enhanced monitoring procedures. These measures include the use of an admission checklist for therapists that outlines the required documentation and corresponding timeframes for completion. The completed checklists will be reviewed and signed by leadership within the first 72 hours of admission to ensure ongoing compliance.

A checklist was provided via email and added to the document library for review.

Additional documentation such as corrections made to the service plan reviewed was requested.

3/10/2026 - Documentation was received indicating this rule is in compliance.


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

raw_content: EBI 4h quarter reports were not submitted.

Correction Narrative: The operation submitted the 4th Quarter EBI Report.


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

raw_content: One personnel record was requested at 10:30 and by 4:30pm the record was not released.

Correction Narrative: One personell record was requested and obtained in a timely manner.


raw_content: One out of two child files did not have an initial service plan.

Standard Number / Description: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

Correction Narrative: Two child files were observed to have intial service plans.


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

raw_content: A television remote with batteries inside was left out on the fireplace accessible to children.


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

raw_content: One of two child files did not have an immunization record.

Correction Narrative: Two child files were reviewed to have an  immunization record.


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

raw_content: RCCR attempted to start reviewing records at 10:30 am, by 1:00pm records were not provided for review.

Correction Narrative: RCCR was able to review records in a timely manner.


summary: 748.3603(m) - Swimming-all indoor/outdoor areas within 50ft outside of pool fence must be free of furniture/equipment a child could use to enter pool area

raw_content: One bench and one pool toy storage box is within 50 feet of the pool gate.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: Two of three serious incident reports reviewed did not have the staff members name listed.

Correction Narrative: An incident report was observed to have staff member and witnesses involved.


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

raw_content: A child attempted suicide twice in May and June. The operation did not report the suicide attempt to RCCR.

Correction Narrative:
The operation submitted the following plan to mitigate risk: A training session will be provided to the staff member responsible for the incident report that was not submitted to the state. This training will review the regulatory requirements for reporting serious incidents, including specific timeframes and procedures for notifying the state of such incidents and proper documentation practices to ensure all serious incidents are accurately reflected in both internal and external reports. In addition, we will have daily checks of our incident reports to ensure we do not miss any state reportable incidents.

On 11/10/2025 a follow up inspection was completed. Documentation was received related training completed for 1 to 1 supervision. The current standard is related to serious incident reporting. Additional information was requested from the operation on 11/14 related to additional trainings completed for serious incident reporting.

On 11/17/2025, the operation submitted email documentation to support a staff member received additional serious incident reporting.


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

raw_content: 2 employees did not have a background check completed while supervising children in care.

Correction Narrative:
The operation submitted the following response to mitigate risk: A comprehensive review of all on-site employees has been completed to ensure each staff member has been properly entered into the state portal. Additionally, a bi-weekly meeting with the Program Director will be implemented to review the state portal regularly and verify that all individuals assisting on site have current and documented background checks.

On 11/10/2025 a follow up inspection was completed. Background checks were verified for all staff members, the staff member involved with the original citation was not present. Background check was observed to be pending. It was communicated with the operation, the staff member cannot be present until the pending status is cleared.


raw_content: Remote batteries were observed to be accessible to children in care following a suicide attempt by using remote batteries.

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

Correction Narrative:
The operation submitted the following response to mitigate risk: All remotes containing removable batteries are now stored in a locked box accessible only to staff. Additionally, a Milieu Rules poster has been posted to remind everyone that only staff members are permitted to use the remotes and that they must be securely locked away when not in use.

On 11/10/2025 a follow up inspection was completed. This rule was recited during the follow up inspection. The rule was corrected at inspection as one remote was placed in a locked box with other remotes. There were no additional remote controllers with batteries accessible to children in care.


raw_content: Data was not reported within 15 days of the end of the 2nd quarter.

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

Correction Narrative:
The operation submitted 2nd Quarter EBI reports. The operation plans to complete the following actions to maintain compliance:

Calendar Alerts- The operation created calendar reminders 2 weeks prior to the end of the quarter to ensure EBI is completed on time during each quarter.

Monthly Progress Checks: The operation instituted monthly internal reviews to monitor progress and address any potential delays well before the quarterly deadline.


summary: 748.3601(9) - Swimming Pool-swimming area rules & emergency procedures must be posted at the swimming area & explained to the children

raw_content: Rules for pool area were not present.

Deficiency Narrative: Rules for pool area were not present.


summary: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

raw_content: 1 of 4 fire extinguishers was not serviced in 2025.

Category: Safety and Emergency Practices

Correction Narrative: RCCR received photo documentation of the cited fire extinguisher with a new fire inspection tag dated August 2025.


summary: 748.3603(g) - Swimming-Fence gates must open outward away from the pool & must not be propped open

raw_content: Two fence doors were observed to be broken.


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

raw_content: Severe weather drills were not completed in 2025.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: Two child files were reviewed. Questions posed to make a determination for suicidality was not available in the child's files. The suicide assessment documents results as "not present." The operation submitted policies that indicate a rating of High to Low risk.


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

raw_content: 2 children were presribed new psychotrophic medications without medical consent. Documentation does not support consent was provided for new psychotrophic medications.


summary: 748.399(b) - Records Available for Licensing - reasonable access to storage and file areas

raw_content: The operation stated their policy is to release individual documents via email. The operation did not provide  access to the EMR for the inspection.


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

raw_content: Fire inspection was completed 13 months after the previous inspection.

Correction Narrative: The following response was provided by the operation:  We(the operation) have coordinated with a staff member from Inspection Operations at the City of Plano to ensure that the annual fire inspection is scheduled in advance for the upcoming year, immediately following the completion of the current year's inspection. This proactive approach is intended to maintain compliance and prevent future delays.


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

raw_content: Four Employees were missing their annual training for Normalcy.

Category: Training and Professional Development

Correction Narrative: The staff has completed their delinquent training. The agency has changed their internal training records to ensure all staff are completing their training in accordance with the standards.


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

raw_content: Operation failed to report a serious incident timely.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operation administration placed children at risk when they fail to increase staff when additional supervision was needed.

Correction Narrative: Email from operation administrative staff with training documentation. The staff have been retrained.


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: Two children in care files did not have a dental exam.

Correction Narrative: The administrator stated in the future the operation will have children in care completed dental examination within 30 days of admission.


summary: 748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children

raw_content: Multiple children indicated that they do not have any hot water in the shower.  in addition, there was no hot water in the sinks.

Correction Narrative: An inspection was conduct and all showers and sink were tested. Children in care were interviewed and confirm they have hot water to shower with.


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: Children in care were not dispensed prescribed medication according to instructions.

Correction Narrative: All operation staff took additional medication administration training. Since staff shift may varies all employees have been training to administer medication to children in care.


summary: 748.303(e)(3)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness if an adult contracts a reportable communicable disease

raw_content: The agency did not report to Licensing when staff contracted a communicable disease.

Correction Narrative: The operation provided a plan where they will report communicable disease within 24 hours of awareness.


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

raw_content: Several children that were interview stated that they are yelled at by staff.

Correction Narrative:
Children in care were interviewed and stated staff does not yell at them.

3-4-22- The operation provided a plan where staff will take additional training each year to address communicating compassionately and sensitive.


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 did not address any supervision needs.

Correction Narrative: The operation added an additional section to the preliminary service plan that addressed the supervision needs of children in care.


facility_name: ACH Child and Family Services

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

raw_content: A child in care did not receive medical care timely.

Correction Narrative:
On 1/14/26, RCCR Inspector conducted an inspection and spoke with staff about the protocol and training received concerning incidents. The protocol was also discussed with the program manager. Staff have been informed to contact the nurse for assistance as well to ensure any child receives the appropriate medical care.

On 1/12/26, the director stated that Program Manager held an all staff meeting January 7th. In this meeting staff were re-trained on protocols for incidents involving injuries to clients as well as informing the staff nurse when there are any incidents with youth involving physical contact. The nurse will then make decisions on the best medical practice to ensure the needs of the youth are met as well
as provide advice for next steps.


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

raw_content:
During walk through of the kitchen food items were found to be expired.

Follow-up update 01/16/2026, the operation has corrected the deficiencies.

Correction Narrative: The found items were removed by the caregiver at the inspection at the home. The item is complaint at this time and there no further review or assessment needed at this time.


raw_content:
Operation did not administer the medication to the child  as instructed.

Follow-up update 01/16/2026, the operation has corrected the deficiencies.

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

Correction Narrative:
On 1/14/26, RCCR Inspector conducted an inspection at the operation to review medication record. There were no concerns. The staff are doing random audits, and the nurse is conducting weekly audits to ensure medication is administered and documented correctly.

On 12/26/25, Director sent an email to address the citation. It was stated that there have been administration changes and process changes to include an improved medication oversight and audit process.  To ensure compliance the nurse is conducting weekly audits on medication logs with follow-up to the respective supervisors to address any needs as well as completing pill counts daily after each shift and training around any areas of concern. In addition, the Program Manager will routinely audit these plans to ensure compliance with this standard.


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

raw_content: The service plans reviewed had the same supervision requirements, as well as the same generic statements documented.

Correction Narrative: Inspector received an email from administrator concerning the compliance. Administrator, met with the staff to review the requirements for documentation of supervision in service plans. The deficiency was discussed with them. All service plans for current youth by 7/21/25 and any needed corrections made. In addition, the Clinical Manager will routinely audit these plans to ensure compliance with this standard.


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

raw_content: Staff members did not intervene, when another staff was using inappropriate discipline techniques that could have caused injury to a child.

Correction Narrative: Two staff who were a part of the incident are no longer with the operation. Additional training concerning EBI was conducted with the rest of the staff.


summary: 748.2451(a)(4)(A) - Seclusion-Only for child with ED or PDD when 25+ children with ED or PDD or >30% of children with ED or PDD; not allowed for child in therapeutic camp

raw_content: After placing a child in their bedroom, the staff member blocked the door by using their foot, preventing the child from opening or leaving the bedroom.

Correction Narrative: A meeting was conduced was conducted with staff concerning seclusion and children. Staff also signed a memo concerning seclusion. Staff involved no longer employed with operation.


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

raw_content: A staff member inappropriate intervene when a child would not return to their room.  The staff member grabbed the child by the arm and then drugged across the room. The child was then picked up and carried to their room.

Correction Narrative: Two staff who were a part of the incident are no longer employed. Additional training concerning EBI was conducted with the rest of the staff.


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: A staff member did not complete EBI training that was due on 04/15/25.

Correction Narrative: Staff who was a part of the incident is no longer employed. The rest of the staff took part in an EBI training.


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:
One out of four children's rights reviewed did not have a signature for the child.

The child was at the operation and signed the form during the inspection.

Category: Children's Rights


summary: 748.3237(c) - Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector

raw_content: The emergency doors are locked and have a ten second delay when the alarm is set off not allowing the children to easily open the doors.

Correction Narrative: Inspector received an email from the administrator with an updated fire inspection and a floor plan stating if the fire alarm goes off all doors automatically unlock and there is free egress. This means the door unlock automatically. A copy of this plan is in the CLASS library.


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

raw_content: A caregiver did not demonstrate prudent judgement when throwing a bean bag at a child's head.

Correction Narrative:
Inspector spoke with director. The director stated that they reviewed of the video coverage from the incident was conducted with program leadership and identified staff. Thorough debriefing was conducted by the Secure Assessment Facility's director. The debrief happened 3/7/24 with the staff member. They discussed and provided additional training on how to properly intervene in the event that a client has gotten into a restricted area.
In addition, ongoing training has been conducted and will continue to be done with direct care staff regarding de-escalation techniques, and how to identify the proper technique for various situations.
The youth is no longer at the operation.


raw_content: A safe environment was not provided when a child was able to gain access to a medication room, left in the room out of the view of staff, and throw objects stored in the room at staff.

Correction Narrative:
Inspector spoke with director. The director stated that they reviewed of the video coverage from the incident was conducted with program leadership and identified staff. Thorough debriefing was conducted by the Secure Assessment Facility's director. The debrief happened 3/7/24 with the staff member. They discussed and provided additional training on how to properly intervene in the event that a client has gotten into a restricted area. The maintenance worker also checked the window shade to ensure the lock was working properly. Inspector took photos and a video of the window locked and unable to push open.
In addition, ongoing training has been conducted and will continue to be done with direct care staff regarding de-escalation techniques, and how to identify the proper technique for various situations.
The youth is no longer at the operation.


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

raw_content: The evaculation plans do not designate where the staff and children are to meet after they leave the building.

Correction Narrative: RCCR Inspector received a copy of the updated evaluation plan. They replace the old ones at the operation. They note the meeting place. A copy is updated in the Library.


summary: 748.1207(a)(2) - Placement agreement-Must include a medical consent form signed by a person legally authorized by Texas Family Code to provide consent

raw_content: One out of one children files reviewed had the medical consenter form completed with the GRO staff and not the child's worker.

Correction Narrative: The director sent a copy of the medical consenter form with the child's worker's signature. A copy has been uploaded to the library.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: The operations policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate.

Category: Organization and Administration

Correction Narrative: Agency administrator submitted policies and were approved by RCCR.


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

raw_content: Floor Plan did not include the severe weather shelter locations, or the meeting place for the fire evacuation.  This was edited during the inspection.


summary: 748.105(6) - Personnel Policies - Develop written policies on whether caregivers may take children away for day/overnight visits, ensure policy meets requirements.

raw_content: The polices included parents written approval for overnights over 72 hours but did not include overnight visits under 72 hours.  Further policy did not include information regarding staff taking children away for personal day or overnight visits.  This was corrected on inspection.


summary: 748.125(d)(5) - Suicide Screening- Must be performed in a manner that protects the childs privacy.

raw_content: The operations policy does not address how the operation will conduct screening in a manner that protects the childs privacy.


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

raw_content: The operations policy does not address who will serve on the postvention team or address this standard in the policy.


summary: 748.125(c)(1)(B) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of safety planning.

raw_content: The operations policy does not indicate which training curriculum the operation will use to train staff, volunteers or non-employees.


facility_name: Adullam Homes, LLC

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

raw_content: A person became a controlling person of the operation effective 12/1/23 and did not notify CCR until 12/15/2025.

Correction Narrative: Operation submitted a new application with the new controlling persons.


summary: 748.709(c) - Name of each designated person must be documented on the face sheet of the child's record

raw_content: In two of the reviewed child records, the designated person's information for making decisions regarding childhood activities was not included.

Correction Narrative: The operation's administrator has indicated that the resident's files will include the information regarding the designated person to make decisions on the child's behalf. The administrator has also submitted corrected and updated face sheets of the previously reviewed files. The RCCR Inspector reviewed the submitted documentation and verified that the missing information had been added to the face-sheets.


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 evacuation diagram of the operation does not specify the location of the shelter within the operation.

Correction Narrative: The operation's administrator submitted the operation's floor diagram, which had been updated. The RCCR Inspector reviewed the evacuation diagram and confirmed that the location of the shelter-in-place had been marked on the diagram correctly.


summary: 748.1439(b)(1)(F) - Discharge Documentation-Discharge summary must include aftercare plans and recommendations

raw_content: One discharge summary did not document the required information.

Correction Narrative: The administrator of the operation submitted an updated discharge summary of the child's file that included all the required information. The RCCR inspector reviewed the file and verified that the aftercare plans and recommendations were included in the summary.


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: One of two Child Service Plans reviewed did not address the child s high-risk behaviors as noted in their placement documents.

Correction Narrative: The operation submitted an updated service plan, which was reviewed by the RCCR inspector to ensure that the plan was properly updated. It was confirmed that the high-risk behaviors identified for the child were included in the service plan.


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

raw_content: A caregiver did not provide one-on-one supervision to a child in their care on more than one occasion.

Correction Narrative: RCCR inspector conducted a walk though of the home on 12/9/25. The were no physical site concerns. One staff interviewed stated CPI training was conducted where supervision and deescalation was refreshed. There is a child who is one on one, They remain in eyesight and proximity to staff. Staff keep all children in eyesight and are upstairs the same time as them and downstairs as well. They remain with staff when outside and on outings. The children are not allowed to wonder and staff always knows where they are.


summary: 748.319(a) - AP Within five days after you receive notification of a deficiency as described in 748.317 you must notify the parents of each child admitted.

raw_content: The operation did not notify parents within five days of receiving notification of the child rights deficiency.

Correction Narrative: 10/29/2025 - The LCCA has provided a response indicating that, moving forward, the admin team will be responsible for completing Form 7266 to provide notification to parents, and the LCCA will be responsible for sending the documents to them in a timely manner. The notice to parents was issued on 10/28/25.


summary: 748.2551(b) - EBI Implementation-The caregiver must act to protect the child's safety

raw_content: A caregiver did not intervene during a physical altercation between two children, which resulted in a third child intervening to separate the fight.

Correction Narrative:
10/27/2025 - On October 29, the administrator will contact a certified instructor to schedule a refresher training session for caregivers on de-escalation techniques and proper interventions. The LCCA will monitor the course and provide certificates.

RCCR conducted an unannounced follow up inspection on 11/4/2025. Staff were interviewed regarding EBI. Staff reported they know they must intervene, de-escalate and redirect children in care to keep the children safe. Staff reported they are up to date on their EBI, SAMA and de-escalation trainings. Children in care were interviewed, and reported staff keep them safe by de-escalating and redirecting them. A walkthrough of the facility was also conducted, and no concerns were observed.


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

raw_content: It was determined that the documentation relating to an incident did not include complete information about the event, and that the information included was inconsistent with the statements of the individuals involved and with a related documented report.

Correction Narrative:
10/27/2025 - On November 1, 2025, the LCCA and administrative staff will offer refresher training to caregivers regarding proper documentation. Additionally, the administrative team will perform daily audits of the documentation.

RCCR conducted an unannounced follow up inspection on 11/4/2025. Staff were interviewed regarding documentation at the operation and reported they ensure documentation is done thoroughly and accurately. Staff reported the administrator talked to them and went over documentation.


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:
10/27/2025 - On October 29, 2025, the LCCA will contact a certified instructor to schedule a refresher training course. This course will be provided to caregivers regarding trauma, CPI, EBI, and supervision. The LCCA will monitor the course and provide certificates.

RCCR conducted an unannounced follow up inspection on 11/4/2025. Staff were interviewed regarding EBI/children's rights. Staff reported they know they must de-escalate and redirect children in care to keep the children safe. Staff reported they are up to date on their EBI, CPI and de-escalation trainings. Children in care were interviewed, and reported staff keep them safe by de-escalating and redirecting them. A walkthrough of the facility was also conducted, and no concerns were observed.


raw_content: It was determined that a caregiver left the operation without authorization, resulting in a caregiver being out of ratio due to a child requiring one-on-one supervision.

Correction Narrative:
10/27/2025 - The administrator submitted a response stating that the caregivers will remain on post until their scheduled shift is over or until the facility is calm in the event of a crisis. The administrator and administrative staff will be responsible for monitoring this.

RCCR conducted an unannounced follow up inspection on 11/4/2025. Staff were interviewed regarding supervision and ratio. Staff reported they ensure to always supervise the children in care and stay in ratio, including children with 1:1 supervision. Staff stated they know they must stay at the operation during the duration of their shift. Children in care were interviewed and reported no concerns for supervision. A walkthrough of the facility was also conducted, and no concerns were observed. The ratio was compliant at the time of the inspection.


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 has not yet completed its annual fire inspection. The previous fire inspection was conducted on July 24, 2024.

Correction Narrative:
9/22/2025: The operation scheduled a fire inspection with the Fort Bend County Fire Marshal, which was completed on September 22, 2025. The operation's administrator submitted a copy of the fire inspection report via email. The report reflects passing status in all categories.

Follow up Date: 9/16/2025 (Follow-up method: Email) - The administrator communicated with RCCR Inspector Mayra Ortiz via email and stated that the inspection with the fire marshal is scheduled for Monday, September 22, at 10 a.m. The administrator requested an extension for 09/24/2025. The extension was approved by RCCR Supervisor Takori Harris on 09/16/25, the original compliance date listed as 09/05/25 was extended to September 24, 2025 to give the operation time to complete the scheduled fire inspection on 09/23/25 and also to provide a copy of the fire marshal's inspection report.

09/05/2025 - The administrator submitted a response indicating that, moving forward, administrative staff will schedule the necessary inspections two months before they are due. In the event that repairs are required, they will be completed before the inspection is due. Furthermore, the administrator submitted documentation verifying payment for the scheduled fire marshal inspection tentative on the week of September 8, 2025. RCCR Inspector Mayra Ortiz has requested that the operation submit a copy of the fire inspection report once the inspection is completed.


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

raw_content: A bathroom on the second floor has a urine odor, the wardrobe door in a childs bedroom is broken off and a cabinet in the kitchen is broken off.

Correction Narrative: A compliance plan was submitted stating that the administrator and program manager will conduct daily walkthroughs of the operation. They will ensure that the staff understands the importance of the house rules. Additionally, the operation submitted photographs of the repaired wardrobe and kitchen cabinet.


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

raw_content: Residence were being charged gas money for transportation.

Correction Narrative:
The administrator reported that the operation will no longer act on the advice of another organization regarding normalcy.
Additionally, residents will not be asked to contribute to the cost of gasoline for transportation.

An inspection was completed at the operation on 8/12/25. No additional concerns were assessed during interviews with the children in care.


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

raw_content: Multiple children advised that staff use profanity and abusive language when speaking to them.

Correction Narrative: The administrator confirmed that the staff received a refresher course on communication, as well as permitted and forbidden disciplinary methods. The administrator provided the training curriculum and the post-test completed by the staff on 8/13/25.


raw_content: Staff was found asleep on the premise.

Deficiency Narrative: Staff was found asleep on the premise.

Correction Narrative:
Email response: The administrator and Program manager will be conducting a refresher class on supervision training 5/27/2025. Program manager will also work on a decreasing hours worked to help keep staff refresh.

Follow up inspection 6/9: Staff conducted in person training on 05/27/2025 for all staff on supervision. The operation reduced staffs from hours from 120 to 112 hours per paid period. Staff conduct multiple walkthroughs throughout day to ensure staff is completing all required task. Staff has daily remainder conversations with staff to ensure staff understands the important of supervision while child in care is present.  Operation is in the process of hiring more staff.


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

raw_content: Two staff files were missing the pre-employment reference checks.

Correction Narrative: Administrator had all staff completed the pre-employment documentation and it was completed 04/09/2025. Administrator will audit the staff files monthly to ensure all required documentation by the state or minimum standards.


summary: 748.363(11) - Personnel records-Include proof of request for background checks.

raw_content: One staff file is missing required documentation.

Correction Narrative: Administrator had all staff print out the request the background check and added it to the staff file checklist. Administrator will audit the staff files monthly to ensure all required documentation by the state or minimum standards are provided upon request.


summary: 748.127(b)(2) - Operation plans, policies, and procedures formalized when signed by each partner in a partnership

raw_content: Policies and procedures were not sing or indicate the date policies were approved and adopted.

Correction Narrative: Administrator ensured policies and procedures book is signed and dated. Copy was provided upon request.


summary: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

raw_content: One staff member took a drug test on 03/28/2025 and the drug test kit expired on 03/16/2025.

Correction Narrative: Email Response 4/15: The administrator team will check expiration date on the drug test before administering. New exam was provided for 4/10 and marked as Negative.


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

raw_content: Two staff files were missing orientation documentation.

Correction Narrative: Administrator had all staff retrained and it was completed 04/09/2025. Administrator will audit the staff files monthly to ensure all required documentation by the state or minimum standards.


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

raw_content: The operation has not been conducting monthly fire extinguisher inspections.

Correction Narrative: Administrator implemental a monthly walk-through checklist that will be verified by administrator once complete. Documentation will be available upon request


summary: 748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented

raw_content: The operation has not conducted monthly smoke detector inspections.

Correction Narrative: Administrator implemental a monthly walk-through checklist that will be verified by administrator once complete. Documentation will be available upon request.


summary: 748.863(a)(5) - Pre-Service Training- Caregivers who administer medication must have psych medication training before administering psych meds.

raw_content: One staff file did not have any pschy medication training certificate.


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: A staff file had other test results in place of required test results.

Correction Narrative: Administrator received a copy of the correct TB test results and is in the staff's file. Administrator will be conducting monthly audits to ensure all required documentation by stated or minimum standards is provided in the staff file. Administrator will also review all documentations prior to putting items in staff file.


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

raw_content: Health inspection letter expired on 01/09/2024.

Correction Narrative: Administrator provided a letter by the health inspector. Administrator also added a remainder to the outlook calendar to ensure to request letter annually.


summary: 748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills

raw_content: Two staff files were missing any documentation stating they can perform their assigned task.

Correction Narrative: Administrator added the requirement to the direct care staff job description memorandum. Administrator will audit the staff files monthly to ensure all required documentation by the state or minimum standards upon request.


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

raw_content: During a review of personnel records, three staff members files were missing the Pre-Employment Affidavit.

Correction Narrative: Received a corrective action plan from the facility stating that a new pre-employment affidavit was signed by each staff and will be used moving forward.


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

raw_content: During the inspection, one out of three children files reviewed is missing the initial service plan.

Correction Narrative: Received a corrective action plan stating that an initial plan was requested by the administrator on 8-25-24 by correspondence via email to the DCFS caseworker which was put in the children's binder on 9-10-24


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: During a review of three personnel files, there was no documentation that a reference check was performed.


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 annual fire inspection was not completed timely.

Correction Narrative: I, RCCL Inspector Michonne Chandler received a completed fire inspection report via email from the administrator.


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: A safety plan was never put in place to address the child's high-risk behaviors.

Correction Narrative: I, RCCL Inspector Michonne Chandler received a corrective action plan from the operation stating that Documentation of assessment for high-risk behaviors and safety plan has been completed and added to the child's file.  All staff have been made aware.


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

raw_content: A child was unsupervised when he climbed out of the window to stand on the roof of the operation.

Correction Narrative: I, RCCL Inspector Michonne Chandler received a corrective action plan from the operation stating that they will continue constant monitoring of children in care at all times while in Adullam Homes care.  1 on 1 if needed.


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

raw_content: It was found that window blinds was covered in a gray powder and a closet had writing  in a child's room

Correction Narrative: The operation sent the following correction by email. The administrator will conduct training on proper cleaning of the facility with staff and youth do that youth will be in a safe place per minimal standards.