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

raw_content: During the course of the investigation, it was discovered May records for a child were shredded.

Correction Narrative: Helping Hand Home has established a new system for how they will be handling medication administration record errors in documentation and/or other corrections. As of 9/27/2021, the healthcare team at HHH will maintain custodianship of each medication administration record needing correction, with a list of staff members who need to complete said corrections. Direct care staff members and their supervisors will be sent an email with details explaining details about the medication administration records needing their attention. Direct care staff will be expected to complete these corrections within two days of receiving the email. Reminder emails will be sent to staff and their supervisors if healthcare staff notice delinquency on corrections. This will continue until medication administration records are completed in full. Additionally, as of 10/1/2021, all medication count sheets will include a medication rationales page with details explaining the reason the medication has been prescribed, the date the medication was started, and potential side effects to look out for as well as contraindications to the medication(s). Medication administration records will be reviewed monthly by the healthcare staff for needed revisions, corrections, or other attention to ensure all medication is being administered and documented correctly by direct care staff. Once medication administration records have been deemed complete and ready to file by the healthcare team, they will be given to the client records manager, an individual who does not administer medications, for a second and final review to ensure all medication is being administered and documented correctly by healthcare and direct care staff.


state: TX

facility_name: Helping Hand Home for Children

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

raw_content: During the course of the investigation, it was discovered a child was given correct medication but was documented incorrectly.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
Helping Hand Home has established a new system for how they will be handling medication administration record errors in documentation and/or other corrections. As of 9/27/2021, the healthcare team at HHH will maintain custodianship of each medication administration record needing correction, with a list of staff members who need to complete said corrections. Direct care staff members and their supervisors will be sent an email with details explaining details about the medication administration records needing their attention. Direct care staff will be expected to complete these corrections within two days of receiving the email. Reminder emails will be sent to staff and their supervisors if healthcare staff notice delinquency on corrections. This will continue until medication administration records are completed in full.

Additionally, as of 10/1/2021, all medication count sheets will include a medication rationales page with details explaining the reason the medication has been prescribed, the date the medication was started, and potential side effects to look out for as well as contraindications to the medication(s).

Medication administration records will be reviewed monthly by the healthcare staff for needed revisions, corrections, or other attention to ensure all medication is being administered and documented correctly by direct care staff. Once medication administration records have been deemed complete and ready to file by the healthcare team, they will be given to the client records manager, an individual who does not administer medications, for a second and final review to ensure all medication is being administered and documented correctly by healthcare and direct care staff.


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

raw_content: Due to the information gathered throughout the investigation, a child in care who was kicking a bean bag and talking to staff was then subjected to an unapproved EBI without providing de-escalation. The incident did not arise to an emergency situation that warranted an EBI.

Correction Narrative: Staff member was immediately terminated since the date of the investigated incident. The operation has renewed EBI training for all employees throughout the month of October and will emphasize, as always, that only sanctioned physical interventions are allowed and restraint is only to be used as an emergency response when all other lesser restrictive interventions have failed to stop the risk of imminent harm.


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

raw_content: It was determined that a caretaker was hired on 5/17/2021. Fingerprint was cancelled on 08/09/2021 due to non-compliance, fingerprints not completed by the due date. It is documented that caretaker was fingerprinted on 08/20/2021. caretakers fingerprints were not received and cleared until 08/25/2021. The incident subject to this investigation was on 08/08/2021. caretaker was allowed to care for children without having a cleared background check.

Standard Risk Level: High

Correction Narrative: The employee related to the background check finding is also no longer employed at the operation.


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

raw_content: On 04/22/2021 the operation was emailed requesting documents, pertinent to the investigation to be provided in five business days. After not receiving a response, a follow-up email was sent on 05/10/2021. requesting the aforementioned documents be provided by 05/11/2021. A response was again not received therefore an unannounced inspection was conducted.

Standard Risk Level: Medium

Correction Narrative:
On 0-15-21, Micki Marquardt from Helping Hand Home emailed me the follow up plan to ensure this does not happen again.
"Hi Eduardo,

I did speak with Mr. Lujan about this.  We will be certain to have an Out of Office message with a back-up contact anytime we are unable to check emails daily during the work week.  We will also go back over the weeks emails each Friday to be sure none were missed or overlooked throughout the week.

Additionally we could create an email just for these requests that would include a group of people authorized to respond.  That way those in the group could respond if either myself or Mr. Janawicz are unavailable in a timely manner.  Please let us know if that would be helpful and we can create that address and share it with your office."


facility_name: Bridgeway Home-Montgomery County Youth Services

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

raw_content: Staff records reviewed indicated Psychotropic medication training had expired.

Correction Narrative: Email was received showing staff training was completed and updated.


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: One child medication log reviewed showed a child received same medication twice for 3 days.

Correction Narrative: CCR Inspector went to the facility and counted medication to make sure the logs and medication matched.


summary: 748.4231(a) - Admission assessment for emergency and respite care services-must include an initial evaluation of appropriate placement of the child

raw_content: 3 of 3 files looked at did not have completed admission assessments.

Correction Narrative: On June 13, 2024 the Administrator emailed a copy of  the new Admission Assessment. This document was reviewed and found to have all required sections for new placements.


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: Two of the four requested files were not immediately available and not all information was able to be reviewed.

Category: Reports and Record Keeping

Standard Risk Level: Medium Low

Correction Narrative: An email was received from the Administrator and stated the following: all files are being audited by the admin team to ensure all documents are completed; all files will be copied and brought from the HR office to the Shelter by 2/16/2024; moving forward any new info/documents for current files will be scanned and stored electronically and documennts will be printed and put in the paper file within 24 hours; when new hires are onboarded the required documents will be scanned and filed in the electronic and paper files and an employee checklist will be updated to reflect the minimum standards.


raw_content: A child's medication was not taken as prescribed.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

Correction Narrative:
An email was received on January 23, 2024 stating the following:
-	Shift supervisor will assign specific staff to administer medications.
-	If a shift supervisor is on shift, they will e responsible to administer medication in both cottages.
-	If there is limited staff and the supervisor cannot dispense medication in the opposite cottage, Shift Supervisor will be responsible to ensure medication is dispensed accordingly via radio communication.
-	In the event the person assigned to medication is unable to attend or complete the shift, the on-call supervisor will be notified unless an administrator or supervisor is already on campus. The on-call supervisor will assign a new staff to administer medications.
-	Shelter Administration will conduct monthly reviews of medication dispensing and management during shelter administration meetings.
-	Staff will regularly updated in staff weekly meetings on any changes in medication protocols and conduct periodic refresher courses.
-	Shift Supervisors will conduct regular supervision and continuous oversight to monitor medication administration process.
-	Shift Supervisors will conduct regular medication audits to ensure dispensing compliance.
-	Shelter Administration will regularly evaluate the effectiveness of the corrective action and make adjustments as needed to ensure sustained improvement in medication administration.
A walk-through was completed on 2/5/2024  and three children s medication and medication records were reviewed.  These were in compliance.


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

raw_content: A child in care was verbally and physically assaulted other children in care while staff watched.

Correction Narrative: The staff member involved was terminated immediately on the night of the incident.  All staff were required to complete a mandatory virtual training titled "Crisis Prevention & De-Escalation: A Trauma Informed Approach." The training required a pre-test and post-test.  Cameras throughout the cottages are randomly checked at minimum of four hours a month.  The COO, Compliance Officer, Shelter Director, and Assistant Direct are in charge of randomly checking footage at varied times. Times and locations are logged on a spreadsheet managed by the administration team.


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 staff was heard cussing and antagonizing a child in care which led to the child being assaulted by staff.


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: During the investigation it was sufficient evidence to find abuse occurred in the operation.


raw_content: A child in care received the wrong dose of medication.

Corrected at Inspection: Yes


raw_content: A child in care did not receive his prescribed medication on 04/10/2023.


summary: 748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days

raw_content: Two children have been in care for over 105 without a placement extension being requested with one still currently placed.

Category: Emergency Care

Standard Risk Level: Low

Correction Narrative: On Friday, February 17, 2023 a variance was submitted for the child in care over 90 days.  A spreadsheet is kept with all children's information and when their 90 day deadline is.


raw_content: A child in care received less medication than prescribed. The perception calls for two pills twice a day, and that child receive one pill, twice a day.

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


raw_content: A child in care did not receive a prescribed daily dosage of medication on 12/25/2022.

Correction Narrative: On February 7, 2023 an email was received from the operation that stated the following: The staff members involved will not administer medication until retrained on February 14, 2023.  Updates to prescriptions will be noted for staff and medication policy will be reviewed with all staff at the next staff meeting, around March 1, 2023.  On February 16, 2023 a walk-through inspection was completed at the operation.  Medication logs were reviewed and found to be in compliance and updated staff training was reviewed.


summary: 748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations

raw_content: Based on the interviews during the investigation the child in care did not receive medical attention after being administered medication improperly.

Correction Narrative: The operation is not allowing the staff involved give medication until retrained. The training will be held at the end of the month.


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

raw_content: During the course of the investigation there was an overdose of a psychotropic medication given to a child in care.

Correction Narrative: Staff was written up and is not allowed to give medication until retrained.


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

raw_content: During the inspection there were medical errors found on the medication logs that were on 7/13 and 7/15. Staff self corrected the dosage and failed to reported to management until 7/17.

Correction Narrative: A physical inspection resulting in a discussion with the administrator about the operation's medication  administration changes made in an attempt to address the recent medication errors. An all staff meeting was held with the meeting's minutes including medication errors, medication policy, mediation talk, resident searches, and room searches. The administrator reported that in addition to the meeting the staff have been issued a step by step instruction manual on administering medications, a medication specialist will conduct daily inventory of medications after administration time periods. Staff have been notified of their requirements to report suspected A/N/E and failure to do so will result in disciplinary actions up to termination.


raw_content: During the inspection, Victim child was aware of being was overdosed on two separate occasions and vocalized this concern during his interview.

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


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

raw_content: During the investigation, the medication error was caught by Staff on 7/17 after the 2nd over dosage  was given.  Incident reported to licensing until 7/19. The over dosage was left unreported and child did not receive medical treatment until 7/20.

Correction Narrative: On 09/20 an email from the operation's manager stated that several steps have been taken to prevent additional medication administration errors. On a physical inspection on 09/23 A physical inspection resulting in a discussion with the administrator about the operation's medication  administration changes made in an attempt to address the recent medication errors. An all staff meeting was held with the meeting's minutes including medication errors, medication policy, mediation talk, resident searches, and room searches. The administrator reported that in addition to the meeting the staff have been issued a step by step instruction manual on administering medications, a medication specialist will conduct daily inventory of medications after administration time periods. Staff have been notified of their requirements to report suspected A/N/E and failure to do so will result in disciplinary actions up to termination.


raw_content: During the inspection of documents it was found in the medical documentation that a child did not receive medical attention until 5 days after the incident and 3 days after a medical error was found.

Standard Number / Description: 748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations


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

raw_content: During the investigation it was found that 6 residents were taken to Dollar General unsupervised inside and were able to steal pills while staff waited in the vehicle. The residents returned to the facility and shared pills amongst each other and several residents were rushed to the hospital due to ingestion.

Correction Narrative: Inspectors received the following information to assist with follow up tasks: Staff and child lists, blank incident reports, updated Level System policy, corrective action for staff on duty at time of incident along with email of corrections. Staff is now PRN due to incident and receiving formal write up. All staff have been reminded of the store request policy that must be completed prior to approval for transporting children off campus.


raw_content: Staff were not following protocol when administering medication to children in care resulting in a child in care hiding pills and taking them back to the bedroom.

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 Director of the Operation submitted the following as a form of Corrective Action Plan which Indicated the following:

CAP is as follows:

All Staff will be retrained on the medication dispensing, counting, and safety with a Registered Nurse on August 03, 2022.

Medication Logs are checked and reviewed by Staff Supervisor and Assistant Director.

No other children, other than the child being given medication, will be in the room at the time of medication dispensary.

Only medication belonging to the child in the room will be pulled and dispensed.

Staff will make sure the child opens moth and moves tongue around to make sure medication is not hidden in the child's mouth, as well as drinks water.

Any Staff with a Medication Error will lead to a formal coaching to include write - up , and possible termination depending on the severity of the error.


raw_content: A child in care had a self harm incident on 4/10/22 that lead to the operation calling EMS to give medical attention to the child. The operation failed to report the incident to Licensing until 4/13/22

Standard Number / Description: 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

Correction Narrative: An email was received from the operation's manager stating that the administrator and staff will were made aware to immediately report serious incidents regardless of the medical professional's diagnoses. A formal meeting will be held on 07/06/22 were staff reporting responsibilities will be reviewed in detail and staff will sign an acknowledgement form. A sign in sheet and staff list will be provided to licensing representative following the meeting.


raw_content: A staff member failed to demonstrate prudent judgement and self control when she engaged in a verbal altercation with a child in care.

Correction Narrative: Correction submitted via email from the administrator stating that the staff member involved received disciplinary action, the importance of professionalism and remaining in control of the situation was discussed, and staff and child apologized to one another and there have been no further issues.


summary: 748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times

raw_content: The operation did not have the required posting Licensing notice Keeping Children Safe or their permit in a publicly visible place.

Category: Organization and Administration


summary: 748.1271(5) - Emergency Admission Documentation-Include known contraindications to the use of restraint

raw_content: Four out of the four child files reviewed did not contain any admission documentation in the file regarding known contraindications to the use of restraints.

Category: Admission, Service Planning, Discharge

Correction Narrative: The administrator email a response stating the following: the administrator met with the therapist  to review the proper protocol and procedural documentation of the contraindications of each residents file. When the administrator and assistant administrator has to sign off on the residents service plans and will check to see that the contraindications have been documented and completed correctly. The administrative staff will ensure that if a common application specifically states a particular type of restraint/coping skills is needed it will be documented accordingly and communicated to the direct care staff.


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

raw_content: In review of medication log, One child's medication log did not documents the child received the medication. On 6-21-2021 the log did not contain a medication count, dose given, or staff signature.

Correction Narrative: I, Brittany Gilcrest RCCR, received an email from Marcel Lue stating the plan of action to Manage the citation, the letter is stored in the file in the investigation. The operation conducted a meeting with the staff to discuss the concern and hosted a training on 10-15-2021 once they learned of the concern. New medication form were designed, Marcel Lue will conducted weekly checks on the medication log and Cathy Reece will report any medication errors to Mr. Lue.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: The operation failed to report the communicable disease to the Texas Abuse and Neglect Hotline more than 24 hours after becoming aware of the positive test results.

Correction Narrative: The operation sent an email response stating that going forward the CEO or the designee will immediately notify the hotline when any type of communicable disease is brought to light.


facility_name: Sweeten Home for Children Inc.

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

raw_content: A staff was recorded on video pushing a child forward.

Correction Narrative:
RCCR inspector received follow up from program director on 2/13/26. Staff was retrained in crisis intervention and EBI on 1/22/26. Staff was retrained on positive kid interaction and child rights on 2/13/26. Staff was placed on a safety plan on 2/13/26.

RCCR inspector conducted an in person walk through at the operation on 2/24/26. Inspector spoke to two staff about training on hands off, EBI and safe interactions with children in care.


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

raw_content: In a review of the incident report, the names of the children who were also present in the vehicle when the incident occurred were not documented as part of the identifying witnesses to the incident.

Correction Narrative: RCCR inspector received follow up compliance from the administrator on 1/22/26. Staff was retrained on reporting policies, processes and how to document serious incident reports on 1/20/26.


raw_content: During the DFPS ANE investigation, this standard was found to be deficient. A staff member used physical force on two children in care.

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

Correction Narrative: This deficiency has been corrected. The staff was terminated. Staff have had additional training in emergency behavior intervention and compassion fatigue. Several staff and children were spoken to and had no further concerns.


raw_content: A staff member admitted to "losing their cool" when interacting with children, and ultimately caused harm to two children in care. The staff was engaging with the children on the basketball court, but the incident escalated and the staff did not use prudent judgement or self-control during the incident.


summary: 748.941(d) - Training Criteria-A health-care professional or a pharmacist must lead the training in administering psychotropic medication.

raw_content: 4 employee files were reviewed for annual training. 2 employee's annual training on psychotropic medication was not provided by a health care official.

Category: Training and Professional Development

Correction Narrative: The operation discussed that they knew a pharmacist that they would get in touch with. They plan to conduct the trainings over zoom due to the pharmacist's location and busy schedule.


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

raw_content: 4 out of 4 children reviewed had a 135 day gap between suicide risk screenings.

Correction Narrative: An email was sent stating "Suicide Screenings will be administered every 90 days after admission for children 10 years of age or older. We have added this task to our "shared calendar" with all staff to insure timely completion."


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: 2 out of 3 EBI reports did not inform the managing conservator of the restraint within 72 hours.

Category: Emergency Behavior Intervention

Correction Narrative: An email was sent stating "All parents will be notified in writing within 72 hours of a Physical Restraint on their child.  Written notification will be attached to the Serious Incident Report."


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

raw_content: Several children and staff interviewed mentioned behaviors they have witnessed regarding Mr. Limon during the course of his duties, including yelling and "horseplay" including wrestling with children in care.

Correction Narrative:
Email received from Scott Russell on 7/12/2023.

"Mr. Limon will receive additional training regarding Discipline and Guidance to improve his competency, prudent judgment, and self-control in the presence of children and when performing assigned tasks.  This training will be completed by 7/12/2023.

We will also continue to implement random camera reviews per our Heightened Monitoring plan to monitor Mr. Limon's interactions with the children and provide him with written feedback of each observation.

Mr. Limon will have a clear understanding that subjecting children to yelling as a discipline measure is not appropriate and should never occur.

Mr. Limon will receive guidance regarding playful engagement (aggressive touch or play such as playing basketball, baseball, football, and general horse play) can trigger negative reactions with some boys that have experienced trauma in their life and should be carefully considered before participating in such playful engagement with each boy."


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

raw_content: During a walkthrough of House A, packages of flour, sugar and rice were stored in open containers in the kitchen cabinets, and shredded cheese, a package of lunchmeat, and a jar of peppers were  stored uncovered in the refrigerator.


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

raw_content: 2 beds in the Big House did not have mattress covers. Staff put the mattress covers on the beds and corrected it during the inspection.


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

raw_content:
During a review conducted on July 29, 2022, it was determined that:

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

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

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

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

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

Correction Narrative: An HM extension was approved effective 07/29/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 01/30/2023.


raw_content: A staff member used a personal cell phone over the course of several months to communicate with a child in care to discuss inappropriate matters and arrange illegal activities.

Correction Narrative:
12.8.22-Inspection conducted at Sweeten Home.  Three staff were interviewed regarding the recent boundaries training and subsequent changes in policies and procedures and all provided details of the trainings and subsequent changes as a result. Staff have already begun new cell phone monitoring procedures and a copy was provided of a completed cell phone monitoring report.

12.7.22-Administrator provided via email training forms for each staff member showing that staff received training on boundaries as well as the updated policies and procedures as discussed on 12.2.2212.

12.2.22-Administrator provided via email updated policies and procedures for monitoring electronic devices, the new monitoring electronic devices policy and cell phone monitoring report, updated telephone policy, and new training form Professional Boundaries with Children Living in Residential Child Care. This training will include the review of the Telephone Policy and Monitoring Electronic Devices Policy as well.

11.30.22-CCR inspector spoke with Administrator by phone as well as email on this date regarding the prudent judgement deficiency.  Administrator confirmed that SWI was contacted as soon as the inappropriate text messages were discovered and perpetrator was immediately banned from access to the physical premises as well as any electronic means of communicating with the children in care, including a safety plan that temporarily removed all electronics from children and not allowing children to go off campus unless accompanied by staff.  Administrator is actively considering a variety of available resources regarding appropriate boundaries between staff and children in residential care that he will begin immediately reviewing with administrative staff and house supervisors in weekly meetings, and these staff will in turn begin communicating these with their direct care staff while a formal training curriculum is developed.  Sweeten Home currently has an electronic device policy that children acknowledge during placement that allows staff to monitor their cell phone usage,and Sweeten Home will continue to require cell phones to be turned in overnight, with monthly cell phone monitoring for inappropriate content to be mandatory for every child in care going forward rather than on a random selection basis as they have done in the past.  Children will be provided with the landline phone numbers for their house as well as their supervisor's cell phone number as their initial points of contact at placement.


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: Investigation by DFPS found that a child in care was exploited by a staff member to obtain and distribute illegal drugs.

Correction Narrative:
12.8.22-Inspection conducted at Sweeten Home.  Three staff were interviewed regarding the recent boundaries training and subsequent changes in policies and procedures and all provided details of the trainings and subsequent changes as a result. Staff have already begun new cell phone monitoring procedures and a copy was provided of a completed cell phone monitoring report.

12.7.22-Administrator provided via email training forms for each staff member showing that staff received training on boundaries as well as the updated policies and procedures as discussed on 12.2.2212.

12.2.22-Administrator provided via email updated policies and procedures for monitoring electronic devices, the new monitoring electronic devices policy and cell phone monitoring report, updated telephone policy, and new training form Professional Boundaries with Children Living in Residential Child Care. This training will include the review of the Telephone Policy and Monitoring Electronic Devices Policy as well.

11.30.22-CCR inspector spoke with Administrator by phone as well as email on this date regarding the child's rights deficiency.  Administrator confirmed that SWI was contacted as soon as the inappropriate text messages were discovered and perpetrator was immediately banned from access to the physical premises as well as any electronic means of communicating with the children in care, including a safety plan that temporarily removed all electronics from children and not allowing children to go off campus unless accompanied by staff.  Administrator is actively considering a variety of available resources regarding appropriate boundaries between staff and children in residential care that he will begin immediately reviewing with administrative staff and house supervisors in weekly meetings, and these staff will in turn begin communicating these with their direct care staff while a formal training curriculum is developed.  Sweeten Home currently has an electronic device policy that children acknowledge during placement that allows staff to monitor their cell phone usage,and Sweeten Home will continue to require cell phones to be turned in overnight, with monthly cell phone monitoring for inappropriate content to be mandatory for every child in care going forward rather than on a random selection basis as they have done in the past.  Children will be provided with the landline phone numbers for their house as well as their supervisor's cell phone number as their initial points of contact at placement.


summary: 748.1337(b)(1)(D)(viii) - Initial Service Plan-Include instructions to caregivers about actions to take or conditions to be aware of in order to meet child's special needs

raw_content: Two service plans reviewed had missing or incorrect medication information.  One service plan omitted a non-psychotropic medication that a child is currently prescribed; a second service plan contained a note that a medication dosage had been changed but the change had not been updated in the detailed table of psychotropic medications.


raw_content: 1 staff member who was on duty consumed an alcoholic beverage. 2 other staff members who were volunteering their time, but still around children in care, also consumed an alcoholic beverage.

Correction Narrative:
The administrator emailed and spoke on the phone with the Inspector to discuss the follow up plan. The three staff members were given written verbal warnings as soon as the operation became aware of the incident.  Verbal written warnings were dated 3/14/2022 and each staff member was told that they are not to consume any alcohol while they are on duty on campus or off campus. Volunteers/Off-duty staff cannot be responsible for supervising children while consuming alcohol beverages.
For future trips, Sweeten Home for Children has taken other measures during lengthy off campus trips (more than 72 hours) that allow staff to have personal time off which includes providing separate housing for staff who are "off the clock".  When staff are "off the clock" they are not responsible for supervising children and are free to conduct themselves as they normally would during "off time".  All staff are aware when they are "on duty" or around children, no alcoholic beverages can be consumed.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: A child was in a prone position during a restraint. The restraint lasted for about 6-10 minutes.

Correction Narrative:
Administrator Scott Russell emailed Inspector Jordan Green the following actions taken:
The three employees that were involved and/or witnessed the physical restraint on Damari received written warnings. (These are attached to the email and will be entered into digital storage.) We reviewed physical restraint policies and procedures regarding prone restraints and time limits for transitional holds.  These employees understand that prone restraints are not permitted beyond one-minute transitional hold and that the child should have been transitioned into a sitting or standing basket hold restraint within one minute of implementing the prone restraint.
Further follow-up on 6/29/22: Also, the operation has Restraint Training coming up again for all staff in late August.  Christy Lewis is certified in Peaceful Intervention and we plan to begin training staff in this Restraint Process starting in August as well. By having a certified Restraint person on staff, we feel that we will be able to enhance our Restraint Training Program and continue to reduce the need for Physical Restraints.


raw_content: A caregiver was rough housing with a child in care that one at least one occasion resulted in the child falling

Correction Narrative: The operation sent documentation that on 3/2 staff Matt was written up for horse playing with children. It reads that TBRI principles were reviewed and alternative interactions were discussed.


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

raw_content: It was found that a restraint was conducted in order have a child comply in returning to the operation as the child was attempting to leave the facility.

Correction Narrative:
The operation administrator sent a detailed corrective action plan via email which shows how the operation will come into compliance in regards to the cited deficiency.

The plan states that EBI training occurred on 9/08/21 and again on 9/22/21 as a result from receiving a citation on this investigation. all care staff were involved in this training where they reviewed the specific incident. It notes their concerns with child safety, specifically in the specific conditions with running into the field behind the operation where snakes and dangerous wildlife can become a danger to children. The plan states that they will not perform a restraint on a child in care in situations similar to this, specifically to keep children from walking into the field as it does not present an immediate danger. This document is uploaded to digital storage.


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

raw_content: Multiple children in care interviewed were yelled at by 2 caregivers. A staff also cursed at a child in care while yelling.

Correction Narrative: The operation reviewed de-escalation techniques with caregivers and also went over ways to prevent yelling or cursing at a child such as stepping away or asking for assistance. This was reviewed specifically with the two caregivers alleged to have yelled


summary: 748.303(a)(6)(B) - Serious Incident-Report to parents as soon as facility aware that child is indicted, charged, or arrested

raw_content: On two occasions the operation did not report that law enforcement came out to the operation to the parent of the child charges were bring pressed against until the next morning

Correction Narrative: The management team received training on 7/26 regarding reporting responsibilities and specifically of reporting to a child's managing conservator regarding an arrest of a child or the police responding to an incident regarding that child at the operation. The action plan is to send an email to the managing conservator directly


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

raw_content: A medication error was not completed for every incident that required one.

Category: Medication

Correction Narrative: A medication error only form was created and submitted. This form will be filed with both houses documents and will be the new expectation when a medication error occurs.


facility_name: La Maison, LLC

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

raw_content: During the review of the investigation, it was determined that an employee was wearing headphones during a night shift preventing auditory awareness of the surroundings.

Correction Narrative: On 02/04/2026, the operation submitted updated policies and procedures to support that headphones are not allowed while on shift. On 2/13/2026 RCCR Inspector, Lindsay Weir conducted an unannounced inspection at the operation and verified that the Employee was awake and not wearing headphones.


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

raw_content: Two staff files did not include the pre-employment screening.

Category: Personnel


summary: 748.935(a)(1) - Annual Training Timeline-Each person must complete the required annual training within 12 months from the date of hire

raw_content: Three staff did not complete The Preventing and Recognizing Youth Sexual Abuse training, and Trauma Informed Care timely.  In addition, four staff did not complete Psychotropic Medication trainings with the 12 months of the previous training.

Correction Narrative:
RCCR received an email from the operation stating that all trainings are tracked within the case management system, extended reach, staff will receive an email when training are expiring in the next 30 days. Staff will complete this as soon as possible and provide a certificate with a date.
If it's not completed by the next reminder which is in 15 days prior to expiration date they will get it done and provide the certificate, all efforts to complete will be documented by email, and failure to complete training will result in a write-up.


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: A child's 72-hour plan does not document information regarding the type of treatment services the child was admitted for, nor does it describe the goal of placement.

Correction Narrative: The operation terminated the staff member involved in the incident, the operation re-trained all remaining staff on non-violent crisis intervention and the preliminary service plan form was updated to include the type of services and goal of the placement.  The operation updated the remaining children currently placed at the operation service plans.


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 was prescribed a medication increase of 2 MG of Guanfacine 1 pill tablets on 7/25/2023. The child has 11 pills remaining at today's inspection.


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

raw_content: During sleeping hours, a staff member was observed lying on the couch. A child in care crawled past the staff member and went into another child's room.

Correction Narrative: On 06/06/2023 the operation's plan for compliance was to implemented 2 motion sensors, 1 for each hallway to alert staff of any movement during the night. -Retraining on 24hr supervision policy occurred for de on 6/2 and ah on 6/3. -Working on hiring additional night staff. Owner Marissa Jubert will make random calls during overnight shifts to check in. Continue to do random pop up visits. On 06/29/2023 an inspection to the operation was conducted by RCCR and it was reported that staff have not been observed as sleeping on duty for the past two weeks. Random calls to the operation were conducted without concern.


summary: 748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest

raw_content: All the bedroom doors were removed except for 1 room.


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

raw_content: The backyard fence was in disrepair it had numerous sharp edges, and some parts of the fence were missing.


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

raw_content: During the course of this investigation, it was determined that a staff use profanity towards a child in care.

Correction Narrative:
The operation submitted a plan to indicate that the employee involved in this investigation was  sent home and then terminated. The policies were
were edited to include a wider range/more specific list of items listed as prohibited to avoid confusion in the future. All staff were retrained on de-escalation techniques and our weapons policy (see attached weapons policy, de-escalation policy). Safety plan was implemented to include new weapons policy. A poster of prohibited items was hung in the staff's office. The operation committed to completing self-checks with staff as a reminder to all staff not to have weapons on the property. New hires signed adherence to the policy.


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

raw_content: During the course of this investigation, it was determined a caregiver used pepper spray against a child as a response to the child's behavior.


summary: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

raw_content: During the course of the investigation, it was determined that the documentation in the serious incident report did not match the statements.


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

raw_content: Staff member did not demonstrate good judgement and control when they escalated a child's behaviors then responded by using a weapon that put other staff and children in care at risk.


raw_content: A caregiver used profane language with a child in care during an altercation.

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

Correction Narrative:
The child was reviewed and observed with no concerns, the child made no outcries and said he loves the operation. On 06/02/2023 the operation reported that discipline training, CPI training, and individualized child engagement training was completed to improve staff's competence. The operation will forward confirmation of these steps to RCCR for verification. The staff's case files will be updated for confirmation. Below are other techniques that can be used to de-escalate a situation:
Positive reinforcement is the most effective form of molding a behavior, and will be used first and in-conjunction with all other forms of behavior intervention.
Specific interventions allowed are described below:
Ignoring:  paying no obvious attention to the youth's negative behavior, in order to extinguish the behavior from lack of attention.
Calm discussion:  listening to the youth to see if you can determine the source of the difficulty and help solve the problem.
Warning:  informing the youth of the unwanted behavior and of the possible consequences if the behavior continues.
Activity restriction:  a youth may be restricted from a specific activity for a specific period of time depending on the severity of the misbehavior.
Quiet time:  allowing the youth at the youth's own initiative to enter and remain in a designated area for a brief period, in order to regain control.
Verbal warning:  a warning may be given to a youth without further disciplinary action and will include the offense, expected behavior and the understanding that repetition of this behavior will result in further disciplinary action.
Loss of Level(s):  A youth may lose a single or more levels, depending on whether the incident was a major or a minor rule violation or the chronic repetition of the misbehavior.
Room restriction:  a youth may be restricted to his room for a specific period of time, the length of which depends on the nature of the misbehavior and the circumstances.  A restriction may not exceed one minute per year of the child's chronological or developmental age.  The reason for the room restriction will be explained to the youth before initiation of the restriction.
Early bedtime:  the youth's scheduled bedtime may be reduced in one-hour units dependent on his behavior.


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

raw_content: A caregiver did not use proper de-escalation techniques with a child in care and continued using profane or other language that escalated the altercation.

Correction Narrative:
The child was reviewed and observed with no concerns, the child made no outcries and said he loves the operation. On 06/02/2023 the operation reported that discipline training, CPI training, and individualized child engagement training was completed to improve staff's competence. The operation will forward confirmation of these steps to RCCR for verification. The staff's case files will be updated for confirmation. On 05/17/2023 the staff involved received CPI training. The portion of the training relevant to this standard is: Below are other techniques that can be used to de-escalate a situation:
Positive reinforcement is the most effective form of molding a behavior, and will be used first and in-conjunction with all other forms of behavior intervention.
Specific interventions allowed are described below:
Ignoring:  paying no obvious attention to the youth's negative behavior, in order to extinguish the behavior from lack of attention.
Calm discussion:  listening to the youth to see if you can determine the source of the difficulty and help solve the problem.
Warning:  informing the youth of the unwanted behavior and of the possible consequences if the behavior continues.
Activity restriction:  a youth may be restricted from a specific activity for a specific period of time depending on the severity of the misbehavior.
Quiet time:  allowing the youth at the youth's own initiative to enter and remain in a designated area for a brief period, in order to regain control.
Verbal warning:  a warning may be given to a youth without further disciplinary action and will include the offense, expected behavior and the understanding that repetition of this behavior will result in further disciplinary action.
Loss of Level(s):  A youth may lose a single or more levels, depending on whether the incident was a major or a minor rule violation or the chronic repetition of the misbehavior.
Room restriction:  a youth may be restricted to his room for a specific period of time, the length of which depends on the nature of the misbehavior and the circumstances.  A restriction may not exceed one minute per year of the child's chronological or developmental age.  The reason for the room restriction will be explained to the youth before initiation of the restriction.
Early bedtime:  the youth's scheduled bedtime may be reduced in one-hour units dependent on his behavior.


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

raw_content: Two employees did not have their TB test results documented in their file during inspection.

Correction Narrative: The agency sent the two employees TB test results via email. These documents can be reviewed in agency file in SharePoint-digital storage.


summary: 748.457(a) - Unauthorized AbsenceTriggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

raw_content: Two children that were previously placed in care did not recived a  trigger review  after  3 unathroized absences with a 60 day timeframe while in care in September 2022.


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

raw_content: During the course of the investigation, it was determined that the operation did not a resolution documented on the serious incident report.

Correction Narrative: On 3/9/2023 RCCR received the updated serious incident report from the operation, with the following resolution documented on the serious incident report. The safety plan was updated for the youth and staff monitored the youths interactions with other youth closely going forward.


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

raw_content: A child was inappropriately restrained.

Deficiency Narrative: A child was inappropriately restrained.

Correction Narrative: Staff member was retrained in correct restraint methods and practices on 09/16/2022. Verification provided from agency.


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: Of the six child files reviewed, three were not signed by the child.

Correction Narrative: Case manager was retrained on maintaining records. Documentation of this is in the employee's file.


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

raw_content: Of the six child files reviewed, three contained service plans that had the wrong effective and start dates documented.


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: Two serious incidents were not reported to Licensing.

Correction Narrative: The agency will report all substantial physical injuries including those that involve physical abuse committed by a child against another child as stated in minimum standards. The administrative team will continue to improve our assessments of substantial physical injury by communicating with the LCCA when an injury occurs to determine if and when to report a serious incident.


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

raw_content: Numerous medication logs did not have the year documented on the forms.

Correction Narrative: Staff have been notified to start documenting the year when documenting medication administration.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: Of the six child files reviewed, four were recommended a PCP follow-up per their CANS Assessment but there was no  documentation to support that this was completed.


summary: 748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services

raw_content: A child's service plan recommended that the child participate in grief therapy and this service is not being provided to the child. Another child's CANS assessment recommended the child see a Developmental Disability Specialist and this was not done.

Correction Narrative: This investigation trained agency staff of proper CANS follow ups. Staff are currently working with life path systems to make sure all requirements are met. All reviewed youth still in placement have been set up with case management and should begin other CANS recommended services soon.


summary: 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

raw_content: Of the six child files reviewed, one had a service plan team meeting invite that was sent out with less than two weeks notice.

Correction Narrative: The agency has created a spreadsheet to track due dates and dates needed to notify case workers. Extended reach also gives a 30-day notice that a service plan is due.


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

raw_content: In June 2021 a staff member violated his conditions of employment and the administrator placed the staff on disciplinary action. The disciplinary action stated the staff would be terminated if the staff violated conditions. In May 2022 the staff again violated the conditions of his employment and the administrator was made aware immediately. As of 06/13/2022 the staff is still present and employed at the operation.

Correction Narrative: The staff member who violated their conditions has been terminated as of 06/14/2022.


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

raw_content: Multiple windows in the facility had damaged and broken blinds.

Category: Physical Site

Correction Narrative: Photos of new blinds installed were received.


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

raw_content: A staff member transported children in care to the bus stop and this was against the staff member's conditions.

Correction Narrative:
As of 06/17/2022 the operation terminated Mr. Snowden's employment and has made his background check inactive.

On 06/13/2022 a follow-up inspection was conducted at the operation and the conditions were observed to be in compliance.
A compliance plan/safety plan was received which stated the following:
- Supervisor will ensure there are 2 other staff on a shift that includes this staff member as much as possible.
- The administrative team met with the staff member on 5/24/22 to review all provisions and ensure understanding across all parties.
- During this meeting, management created scenarios and role played how to properly handle issues while remaining compliant with provisions as a review for the staff member.
- During the staff meeting on 5/24/2022, management discussed with ALL staff what each provision means and how to remain in compliance when working with a coworker who is under any of those provisions.
- Staff will sign this training to ensure understanding of provisions and how to remain compliant.
- All staff who are on provisions will also review and sign their paperwork as a reminder of their conditions


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: A caregiver shoulder checked a child in care.

Correction Narrative: The staff member involved in this incident has been terminated.


summary: 748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules

raw_content: A staff members background conditions were not followed.

Correction Narrative: A staff training was conducted on provisions to ensure understanding from all parties.


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: Child's file did not have a signature in "Child's Rights" section

Category: Children's Rights

Correction Narrative: An email was received from the agency which contained a compliance plan. The compliance plan stated the operation has added the Child's Rights form into their process to just print it and have it ready for all intakes in case the CPS worker forgets it.


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: One child's medication file was missing dosage.

Correction Narrative: An email was received from the agency which contained a compliance plan. The compliance plan stated all staff have been retrained in medication error/protocol. All staff will also receive additional medication training when the operation moves over to electronic filing.


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

raw_content: There are holes in the walls of two rooms. One hole in the wall next to the entry way door. The second hole was on the bathroom door in a seperate bedroom. Blinds have been damaged as well.

Correction Narrative: All holes in walls and doors have been patched and window blinds have been replaced.


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

raw_content: Staff did not report an incident to the hotline within appropriate time frame.

Correction Narrative: An email was received from the facility. The email stated the staff member, as well as all other staff, have completed additional training on reporting serious incidents. A copy of the staff member's training certificate was provided.


summary: 748.3353(c) - Monitoring Devices-Video cameras may not be used to tape the child, and images may not be accessible except to operation employees and caregivers

raw_content: A child was seen being recorded on staff cell phone and the video assessible to others.

Correction Narrative: An email was received from the agency containing a compliance plan which stated the following: management reviewed confidentiality paperwork and had each staff resign the form and placed it in each employee's file, meeting was conducted with staff where it was discussed that staff are not allowed to record the youth or have youth in the background of any personal videos or photos and that confidential information about youth is not to be shared on social media or with anyone not employed by the facility.


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

raw_content: A child was admitted in the program on 04/22/2021. At the time of admission the child was diagnosed with Autism Spectrum Disorder.  The permit type does not offer services to handle the child's level of care. The service plan does not indicate services for emotional disorder.

Correction Narrative: An email was received from the agency that contained a compliance plan which stated the agency reviewed minimum standards and their admission policies and determined youth in their care met all requirements to be admitted into our program and are receiving all required services. The agency accepted the youth referenced on the basis of his/her emotional disorders, the checkbox on the service plan was intended to be marked but was not. Each admission assessment is completed by members of the service team including our Treatment Director, the youth's therapist, Case Manager, etc. This youth is receiving all treatment services available. In the future, the agency will submit a variance if a youth does not meet their admission policy.


raw_content: CBCU notified the La Maison on 6-02-2021 that a caregiver may be present at the operation on a provisional basis.   On 7-26-2021 it was learned that the caregiver was present at the operation and had unsupervised contact with children in care and transported children.

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


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 serious incedent reports did not include all names of the people restaining a child and the steps taken to deescalate the situation.

Correction Narrative: During a phone conversation with Robin H., stated that she will comply in the future by training her staff to be more detail oriented and change the EBI template to ensure that details are given.


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: A staff member's case file did not have a diploma or High school equivalency.

Correction Narrative:
The agency e-mailed a college transcript.
In reference to the employee not having a high school diploma in their file, the employee made several efforts to contact his school overseas and eventually was able to get his transcripts sent. In the future we will have employees take the GED test as requested.


raw_content: A child did not receive their psychotropic  medication as prescribed.

Correction Narrative: Administrator Harbin reported the employee is no longer at the operation.  She provided additional training with employees on medication entries and she redid the medication instructions.


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

raw_content: Two staff members watched a child being abused by a caregiver and did not intervene.

Correction Narrative: Staff at all levels have been reminded of the importance of not only reporting incidents of this nature to their supervisor and the abuse neglect hotline, but also to intervene with protective actions on behalf of the youth if necessary. I have sent all staff several suggestions of how to intervene appropriately as well as how to manage their own behaviors in times of high tension. We will be reviewing the rights of youth in care next week at our staff meeting as well as effective communication strategies. In addition to those things, we have let the offending staff member/supervisor JT go; he is no longer employed at our operation. We have replaced him with a new staff supervisor. We have created a staff trainer position to train new hires. We have all new hires review youth rights during their preservice training in addition to their general pre service trainings on our policies and procedures We self-reported the allegations and will continue to do so to ensure our compliance with minimum standards and the health and safety of the youth in our care. We do not allow the use of threats, intimidation, or physical discomfort as a disciplinary measure.


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

raw_content: A staff member, while using profanity, threatened to harm a 10 year old child in care. This occurred while the child sat in a corner crying and shaking. After the incident the staff member continue the behavior by calling the childs parent a prostitute and a whore.

Correction Narrative: The operation obtained compliance by terminating an employee, retraining staff, and implementing a safety plan to ensure conditions of employment is followed. A follow up inspection was conducted by RCCR to ensure compliance and no concerns were found at the time of the inspection.


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

raw_content: A staff member told a child in care to switch them with a television cord and see what will happen. Another staff member brought the television and placed it in front of the child.

Correction Narrative:
We have let the offending staff
member/supervisor go; he is no longer employed at our operation. We have replaced him with a new staff supervisor. We have created a staff trainer position to train new hires. We have all new hires review youth rights during their preservice training in addition to their general pre service trainings on our policies and procedures. We self-reported the allegations and will continue to do so to ensure our compliance with minimum standard and the health and safety of the youth in our care. We do not allow the use of threats, intimidation, or physical discomfort as a disciplinary measure.


facility_name: Seeds of Royalty

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

raw_content: 2 of 4 employee files were missing  notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home  Form 2985. 1 of those 2 files was also missing  Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations Form 2912

Correction Narrative: 01-29-2026. The assigned inspector emailed the operation and requested a compliance response. The operation responded with copies of the affidavit forms for the employees (files selected in this inspection) created, signed and notarized since the inspection.


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

raw_content: During the walk through mold was seen in the 3rd bathroom under the sink on the left.

Correction Narrative:
02-13-2026. The operation emailed the assigned inspector a larger photo showing the cabinet and the area surrounding it.

01-25-2026. The operation emailed the assigned inspector a photo of the mold cleaned out of the bathroom sink area.


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 operation locks the front and back doors of the operation from the inside.

Correction Narrative: An in person follow up was completed on 1/21/25 during a routine monitoring inspection #4093793. Ms. Rouffin showed inspectors the new evacuation route that the operation had that stated that in an emergency staff and children would exit out of the front windows and front door. Being the home is a one-story home and the front windows to the home that face toward the street are large windows that allows children and staff to exit out if needed. Staff had also been retained on the emergency plan. Confirmation of the emergency training was requested.


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: The CLASS system shows quarterly emergency behavior intervention report for April to June 2025.

Correction Narrative: The assigned inspector observed the operation has now completed the quarterly report and telephoned the operation administrator and confirmed the only reason the operation didn't submit the report on time was due to a technical glitch with the provider access portal.


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

raw_content: During the inspection, there were multiple food items not stored properly as there was no expiration date on foods that were cooked.


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

raw_content: During the inspection, the thermometer in the fridge was not working and there was no thermometer in the freezer of the deep freezer.

Correction Narrative: The operation followed up on the deficiency by providing threw pictures of thermometers with the correct degrees according to minimum standards for the fridge, freezer, and the deep freezer.


summary: HRC42.063(a)(1) - Reporting incidents and Violations-arrest, abuse, neglect, exploitation, running away, attempted suicide, or death of a child

raw_content: A child's suicide attempt was not reported to the statewide intake within the required timeframe by the operation.

Correction Narrative:
The case manager and the adminstrator stated that the only thing that is changing is the advice provided by licensing,  so the operation will report all hospitalizations and report all incidents of self-harm. The csae manager stated that if there is another staff at the operation when an incident occurs, staff will report it to the case manager and the administrator. Then the incident will be reported to the hotline within the required timeframes according to minimum standards.

 I also reviewed incident reports provided from 8/18/2025-9/08/2025 and there were no concerns as the inicidents did not need to be reported as serious incident reports.


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

raw_content: The CPR/First Aid certificate for a PRN staff's file reviewed expired March 2023.

Correction Narrative: I will update my PRNs staff file stating that he is PRN. I will create a training schedule for him based on when he is in town and available to ensure that all of his trainings are able to be completed timely.


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

raw_content: The operation did not exercise prudent judgement when the door of the main office, where the van keys were kept, was left unlocked during the nightshift hours. This allowed a resident access to the van keys, allowing her to drive the van off the property.

Correction Narrative: Staff has attended additional training regarding supervision and prudent judgment in various situations. The facility van keys are now under double lock. They are now locked in the medication cabinet which is locked in the admin office.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: Fire extinguisher expired July 2022.

Deficiency Narrative: Fire extinguisher expired July 2022.

Correction Narrative: Photo received of compliant fire extinguisher.


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: Background checks have not been validated in the past 90 days.


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

raw_content: Two of nine reviewed medication logs had an inaccurate count documented.

Correction Narrative: 3/2/22- Ms. Phyllis sent in a copy of the corrected med logs.


summary: 748.2205(1) - Medication label error-Report medication label errors to the pharmacist

raw_content: A child's medication label was printed to be administered PM when it should have been AM.


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

raw_content: There were four children's records reviewed and four out of four children's records didn't have contraindications to the use of restraints.

Correction Narrative: The administrator sent the information required for follow up via email on 2/8/22. I have reviewed the documentation and compliance is met.


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

raw_content: Serious Incidents to not include the operations contact information.

Correction Narrative: The corrected document was submitted and found to be in compliance.


summary: 748.1437(2) - Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer

raw_content: The Discharge Summary did not include when the child was informed of their discharge.


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

raw_content: Severe weather drill form was not available at the time of inspection.

Category: Safety and Emergency Practices


facility_name: New Horizons Audrey Grace House RTC

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

raw_content: A child in care was grabbed by the arm to comply.

Correction Narrative:
RCCR inspector received compliance plan follow up from administrator via email. The staff directly involved completed training on 3/23/2025 covering the Minimum Standard on Child's Rights. Staff have been instructed to create a safe environment by increasing supervision and decreasing frustration.  AGH has been and will continue to be committed to Keeping Kids First.

RCCR Inspector conducted a walkthrough of the operation on 4/3/25. All medication was double locked and inaccessible to children in care. Staff were compliant in ratio with children and were observed supervising in an appropriate way. Two children were interviewed and asked about discipline, supervision, and medication storage. No concerns were noted.


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 staff member made demeaning, crude, inappropriate comments and threats to children in care.

Correction Narrative: A follow up was conducted at the operation on 4/17/25. 1 staff and 2 children in care were spoken to regarding medication storage,  supervision, discipline, deescalation, EBI, sensitivity and training. There were no concerns noted.


raw_content: The Clinical Director admitted to cussing when children in care were present. Six other individuals confirmed hearing Clinical Director cuss on several occasions while children in care were present, during therapy sessions or in professional settings.

Correction Narrative:
RCCR inspector was emailed compliance plan by administrator via email. On 3/26/2025 a verbal conversation with the Clinical Director regarding acceptable and appropriate language.  A written document will be completed and signed for follow up.  Clinical Director will review minimum standards 748.507(1) and review New Horizons Philosophy and Guidelines around Adult and Child Interactions.

RCCR Inspector conducted a walkthrough of the operation on 4/3/25. All medication was double locked and inaccessible to children in care. Staff were compliant in ratio with children and were observed supervising in an appropriate way. Two children were interviewed and asked about discipline including cussing, supervision, and medication storage. No concerns were noted.


summary: 748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers

raw_content: One child's service plan did not have a caregiver participant/signature when reviewed.

Correction Narrative:
RCCR inspector received the compliance follow up plan for operation Administrator on 3/11/25.

Case Managers will meet on 3/11/2025 to discuss the expectation of direct care staff being involved in the treatment team meeting and participating in the completion of the service plan for children in care in their direct supervision.  If a direct care staff is not present in the treatment team meeting a Team Leader or House Director will be present and provide communication and follow-up to the direct care staff.  All staff will be given the expectation to participate in treatment team meetings and service planning for their direct supervision of kids during the All Staff Meeting on 3/19/2025 when reviewing EBI expectations. The Administrator will send inspector sign in sheet showing all staff were in attendance for training. A sign in sheet was uploaded to the document library regarding the all-staff training.


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: A personal restraint occurred on 2/13/24, but was not documented until 3 days later, 2/16/24.

Correction Narrative: RCCR Inspector was sent compliance follow up from operation Administrator on 3/11/25. The staff directly involved in the report was notified on 3/10/2025 to complete documentation before end of shift.  Any additional follow- ups can be provided an addendum to the report if necessary.  All staff will receive training on 3/19/2025 at the All Staff Training covering EBI training topics. The Administrator sent inspector sign in sheet showing all staff were in attendance for training.


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

raw_content: A child in care had a medication error not reported.

Correction Narrative:
RCCR inspector received follow up plan from administrator on 2/17/25.

 On or about February 12th, 2025, the 6-month monitoring report was shared with all Team Leaders and they were notified to go over medication logs and documentation that includes ensuring that medication error reports are completed within 24 hours. In addition, during our February 19th, 2025, All Staffing/Training, this topic will be discussed in detail with all direct care staff and Team Leaders.


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

raw_content: Four first aid kits reviewed did not have all the required supplies needed.

Correction Narrative:
RCCR inspector received follow up plan from administrator on 2/17/25.

Going forward, the Team Leaders for the night shift shall be responsible for checking and re-stocking all first aid kids in the AGH main house and cottages.


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

raw_content: Three run away incident reports were reviewed. Two of the reports did not include law enforcement notification date and time- One of those two also did not include the name of person notified.  The other run-away incident report did not include name of person spoken to.

Correction Narrative:
RCCR inspector received the compliance follow up plan for operation Administrator on 4/1/25.

All staff completed training on 3/19/2025 regarding this specific Minimum Standard on what to document and when to document and who to notify during a serious incident report.  This was captured in a recent SIR on 3/29/2025 showing effort and focus to improve in this area.


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

raw_content: A child in care had unsupervised access to the medication cabinet that a staff member left unlocked.  As a result of this, the child in care ingested a significant amount of medication in a suicide attempt.

Correction Narrative:
RCCR inspector received compliance plan from administrator via email. All staff attended training on 2/19/2025 regarding Medication Administration and OTC Medication that included keeping medications locked up when not in use and ensuring supervision when medication cabinets are open.  All staff will attend training on the specific standard above no later than 3/24/2025 to ensure competency and understanding in the areas of medication storage related to HHSC requirements.

RCCR Inspector conducted a walkthrough of the operation on 4/3/25. All medication was double locked and inaccessible to children in care. Staff were compliant in ratio with children and were observed supervising in an appropriate way. Two children were interviewed and asked about discipline, supervision, and medication storage. No concerns were noted.


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 left unsupervised with an unlocked medication cabinet, resulting in the child ingesting a significant amount of medication in a suicide attempt.

Correction Narrative:
RCCR inspector received follow up via email from administrator. The staff directly involved was terminated as of 3/19/2025.  All staff received medication retraining on Medication Administration and OTC Medication on 2/19/2025.  All staff will receive training by 3/24/2025 specifically related to the above standard and expectations related to New Horizons Philosophy and Guidelines on supervision of children.

RCCR Inspector conducted a walkthrough of the operation on 4/3/25. All medication was double locked and inaccessible to children in care. Staff were compliant in ratio with children and were observed supervising in an appropriate way. Two children were interviewed and asked about discipline, supervision, and medication storage. No concerns were noted.


raw_content: In a review of the incident report, there are concerns with the times of the runaway notification not being documented to the guardian and to law enforcement. Additionally, the date is not listed for the notification to law enforcement, only the name of the person who was spoken to and the case number are documented. The name of the guardian who was notified is also missing.

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

Correction Narrative: On 1/29/2025, Audrey Grace House administrator sent a compliance follow-up regarding updates to the current incident report template to include a place on the report that will allow staff to enter the time law enforcement was notified, to enter the parent's name, and to enter the time the parent was notified. In addition, the administrator informed that a meeting was held with the team leaders on 1/28/2025, to go over the expectation to enter this information on the report each time a runaway occurs.


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 child's case worker was not notified of the restraint within 72 hours.

Correction Narrative:
On 7/26/24, administrator sent the compliance plan via email to RCCR Inspector.

On 7/23/24, Administrator spoke to staff during staff meeting discussing that written notification will be sent to caseworkers within 24 hours after a serious incident occurs with a child. Specifics are attached and will be uploaded to document library.

On 7/25/24. Administrator notified team leaders of expectations going forward that 30 minutes restraints shall be prohibited when all possible and to follow operations current EBI training when facilitating crisis intervention with children. This included team leaders discussing with staff that supine or prone restraints shall be prohibited when all possible, however, if a supine restraint is needed, it should be as a transition restraint that last no longer than 1 minute. Attached is notification to team leaders and will be uploaded to document library.

Notes from EBI specialist was sent to the operation for more clarification on 30-minute restraints as well as a meeting with the EBI specialist was offered for more discussion.


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

raw_content: A child was restrained for more than 30 minutes. Three children and three staff involved said it was about 35-40 minutes, and the incident report states 38 minutes.


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

raw_content: Three children in care put cleaning supplies into another child's shampoo and on their deodorant. Staff were present during the time of children cleaning; however, the children were still able to obtain and create these mixtures without staff noticing.

Correction Narrative: A follow up inspection was conducted on 6/10/24 at the operation. 3 children in care and 1 staff were interviewed. Cleaning supplies were locked and inaccessible to children in care. Administrator stated cleaning supplies will be handled by staff moving forward and children will be closely supervised during times of cleaning. Compliance plan was discussed for plan moving forward.


summary: 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

raw_content: 5 out of 7 children interviewed stated a night staff was asleep while working.

Correction Narrative: Administrator emailed compliance plan to RCCR inspector on 6/24/24. Administrator retrained staff on supervision policies for night staff. Each night staff reviewed and signed as an understanding of the expectations. Document uploaded to document library.


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

raw_content: Multiple staff and children in care stated an employee cussed at children in care.

Correction Narrative:
RCCR inspector received compliance plan by email from Administrator on 6/2/24.

May 27th, 2024, AGH Administrator met with employee to discuss this citation and to inform them that they were named as the employee who allegedly cursed at children in care. During the conversation, the employee denied the allegation. I advised that this investigation by HHSC concluded that they were named by several children and although they are denying the allegation, all AGH staff must use professional judgment and be able to respond to children's behaviors without using profanity. In addition, they were advised that if a child's behavior has escalated and they do not think they are able to respond appropriately, that the on-duty team leader should be notified, and they could be removed from the area. They indicated that they understood; however, advised again that they have never cursed at children in care. Finally, they were advised that they will continue to monitor their progress from the January 10th, 2024, improvement plan that she was issued.


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

raw_content: All children interviewed reported staff yelling at children, and/or being loud and in their faces. Two staff reported they have seen staff yell or raise their voice when they could have handled the situation better.

Correction Narrative:
On 4/17/24, the administrator emailed RCCR inspector the compliance plan.

 On April 17th, 2024, during our monthly All Staffing/Training, Subchapter H, Child Rights were presented and discussed with staff in attendance. We specifically spent time discussing professionalism and how to respond to children when redirecting them. This was a PowerPoint presentation a long with a group discussion. I have attached the sign in sheet with staff's names confirming their attendance.

On 4/22/24, one employee who was involved in the investigation with a citation was terminated and is no longer employed at the operation.
All documentation will be uploaded to the document 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: One staff admitted calling a child a liar and in a separate incident a different staff admitted making a comment to a child in care stating they should cut down on eating cookies and mashed potatoes, making an implication to weight.

Correction Narrative: RCCR Inspector received compliance plan on 3/21/24 by the Administrator. The Administrator spoke with both staff involved in the citation. When a staff is redirecting a youth in care, this will now require an additional witness to be involved. Both staff agreed that going forward, it's agreed that they will not make any joking remarks to youth that may be interrupted as harsh, cruel, and demeaning that potentially could implicate passing judgment on a child.


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: A medication log stated that a pill was borrowed from another child in care. The campus nurse confirmed that this did occur based on her medical knowledge and approval.

Correction Narrative:
Administrator emailed RCCR Inspector compliance follow up plan on 2/23/24. Staff will check all medications logs for quality assurance to ensure accurate counts, administer correctly, etc. The operations registered nurse will physically review medication logs for accurate counts, expiration dates, administered according to instructions, dates, times, initials of staff, etc. Staff has been instructed not to borrow or administer medications to a child that is prescribed to another person. Staff was trained on psychotropic medication at an all staff training meeting on 1/24/24. A follow up inspection was conducted at the operation on 3/6/24. Medication logs were reviewed with Quality Assurance signatures observed each time a child is administered a medication. Administrator and nurse were both
interviewed and stated a duplicate of the key used to gain access to medication in the nurse's office was made so that staff will not borrow medication but will now have access to the medication refills if the nurse is unavailable. Medication logs are checked for quality assurance by team leads from the shift after theirs in order to have multiple eyes checking each log. The nurse checks medication logs and refills every Wednesday. Staff was given a medication administration refresher training as
well.


raw_content: A staff member admitted to playing games on their cell phone when directly supervising children in care.

Correction Narrative:
Administrator emailed a corrective action plan of the steps taken to mitigate risk on 1/25/24.

1.On or about January 25th, 2024, the Audrey Grace House administrator met with Child Development Specialist staff and discussed the issued citation. We discussed when facilitating supervision duties of children, to refrain from using their cell phone except for during our normal communication needs that may include: communicating with other team members & team leaders related to operational activities. Also, they are allowed to check our daily calendar on their phone and to communicate through our group text. I have included a summary email of our discussion that was sent to the staff member.
2.
On or about January 16th, 2024, during our bi-weekly Team Leaders meeting, all team leaders were instructed to meet with their teams and remind them of their supervision responsibilities and to ensure that they are not using their cell phones for recreational purposes. In addition, Team Leaders are expected to observe staff routinely to ensure they are not using their phone for recreational purposes. As of 1/25/2024, all team leaders have reported back to the administrator of Audrey Grace House that their teams have been met with and expectations were discussed.


summary:
748.3421(3) - Poisons-Ensure poisonous/flammable material is
stored in an area that is inaccessible to children unless child is capable to use responsibly.

raw_content: Cleaning supplies were found in an unlocked cabinet under the sink in a bathroom that is assessible to children in care.